Urologic pelvic surgery following mesh hernia repair.

PURPOSE: Few and controversial reports have recently appeared on the role of previously performed surgery in the inguinal region using a prosthetic mesh and the ensuing difficulties encountered by urologists during radical retropubic prostatectomy. We analyzed our experience with various surgical urological procedures performed after prior low abdominal wall hernia repair with synthetic mesh. METHODS: We reviewed our database for all patients who underwent mesh repair of lower abdominal hernias and subsequent urologic surgery in our department between 2002 and 2008. Their perioperative parameters, complications, and postoperative outcomes were analyzed. RESULTS: Twenty-three patients (one female) underwent pelvic urologic surgery for benign and malignant disease after having undergone previous prosthetic hernia repair. The mean patient age was 75.3 years (range 58-91). The mean interval between hernia repair and pelvic urologic surgery was 3.8 years (range 1-7). Twenty-two patients underwent previous mesh inguinal hernia repair and one had prosthetic postoperative ventral hernia repair after a transabdominal hysterectomy. The urologic procedures included 16 open suprapubic prostatectomies, two radical cystoprostatectomies, one bladder augmentation, and four laparoscopic radical prostatectomies. Severe postoperative complications were abortion of surgery (n = 1), inability to perform lymph node dissection (n = 2), bleeding (n = 1), bladder injury (n = 2), and additional surgery (n = 3: mesh removal, transurethral prostatectomy, and transurethral fulguration of the prostatic fossa). CONCLUSIONS: Prior application of synthetic mesh during abdominal wall surgery creates difficulties during subsequent urological procedures and may dictate change in operative planning. Nevertheless, the surgery is feasible and should not be ruled out.

Diagnostic value of CT-guided biopsy of indeterminate renal masses.

AIM: To evaluate the role of percutaneous core biopsies in the diagnosis of renal masses that could not be classified as benign or malignant based upon imaging alone. MATERIALS AND METHODS: We retrospectively analysed core biopsies of indeterminate renal masses of 23 patients who were referred to us for computed tomography (CT)-guided biopsy from 1996-2001. Follow-up ranged from 1-5 years. Analysis was based on indications for biopsy, size and characteristics of the lesion and accuracy of biopsy results. RESULTS: There was one technical failure in 22 patients included in the analysis. Fifteen core biopsies revealed malignancies that were confirmed either clinically or surgically. Seven were benign, one of which was false-negative. The sensitivity was 93%, specificity 100%, positive predictive value 100% and negative predictive value 75%. The results in tumours <==3 cm were similar to those in larger lesions. CONCLUSIONS: We recommend the use of core biopsy as a diagnostic tool for indeterminate renal masses, regardless of mass size. Renal core biopsy can influence the management of lesions: primary renal lesions are resected, while treatment for metastatic disease is tailored to the primary tumour. Tumours with benign biopsy results should be re-evaluated and either referred for resection of the mass or followed up closely with clinical observation and of imaging studies.

The effect of pneumoperitoneum on dissemination and scar implantation of intra-abdominal tumor cells.

PURPOSE: The role of laparoscopy for the treatment of cancer remains controversial, and a particular concern is port site metastases after laparoscopic surgery. Since laparoscopy is being performed with increasing frequency, the question arises as to whether it is a safe oncological procedure. After intraperitoneal inoculation of renal cell carcinoma cells in a mouse model, we compare abdominal wall scar implantation following laparoscopic trocar insertion and pneumoperitoneum with standard laparotomy, and examine the effects on tumor dissemination in the peritoneal cavity. MATERIALS AND METHODS: Following intra-abdominal RENCA cell inoculation, Balb/c mice were randomized into group 1-20 mice that underwent carbon dioxide pneumoperitoneum and telescope trocar insertion, group 2-20 subjected to laparotomy and group 3-10 anesthetized only. All animals were sacrificed 2 weeks after inoculation, and abdominal wall metastases and intraperitoneal tumor distribution were evaluated. RESULTS: Overall, intra-abdominal implantation of inoculated RENCA tumor cells was detected in 15 of 20 animals (75%) in group 1, 14 of 20 (70%) in group 2 and 10 of 10 (100%) in group 3. Wound metastases developed in 46.7% of the mice in group 1 and 50% in group 2. CONCLUSIONS: There was no difference among the groups in the pattern of intraperitoneal tumor implants and scar seeding incidence. Pneumoperitoneum does not facilitate port site metastases.

The rate of the founder Jewish mutations in BRCA1 and BRCA2 in prostate cancer patients in Israel.

Inherited predisposition occurs in 5-10% of all prostate cancer (CaP) patients, but the genes involved in conferring genetic susceptibility remain largely unknown. Several lines of evidence indicate that germline mutations in BRCA1 and BRCA2 might be associated with an increased risk for CaP. Three mutations in these two genes (185delAG and 5382InsC (BRCA1) and 6174delT (BRCA2) occur in about 2.5% of the general Ashkenazi population, and the 185delAG BRCA1 mutation, in up to 1% of non-Ashkenazi Jews. In order to assess the contribution of these germline mutations to prostate cancer in Jewish Israeli patients, we tested 174 unselected prostate cancer patients (95 of Ashkenazi origin) for these mutations by PCR amplification and modified restriction enzyme digests. Patient's age range was 45-81 years (median 66), and in 24 (14.4%) the disease was diagnosed prior to 55 years of age. Nineteen (11%) and 12 (6.9%) patients had a first or second degree relative with CaP or breast cancer, respectively. Overall, five mutation carriers were detected: 2/152 (1.3%) 185delAG, 2/104 (2%) 5382InsC, and 1/158 (0.6%) 6174delT. In all carriers, the disease was diagnosed after the age of 55, and only one of them had a family history of breast and CaP. In addition, no allelic losses at the BRCA1 locus were demonstrated in 17 patients with a family history of CaP, using seven microsatellite markers. We conclude that the rate of the predominant Jewish BRCA1 and BRCA2 mutations in CaP patients does not significantly differ from that of the general population, and that mutational inactivation of the BRCA1 is rare in familial CaP. Thus, germline BRCA1 and BRCA2 mutations probably contribute little to CaP occurrence, to inherited predisposition, and to early onset disease in Jewish individuals.

Long-term follow-up of patients receiving injection therapy for erectile dysfunction.

OBJECTIVES: During the last decade, vasoactive intracavernosal pharmacotherapy (VIP) has been used extensively for the treatment of erectile dysfunction. However, there is concern about high discontinuation rates and the possibility of long-term complications. Because of few long-term studies on VIP, we investigated efficacy, side effects, satisfaction index, and drop-out rate for injection therapy in patients who started treatment more than 5 years ago. METHODS: Questionnaires were mailed to 108 patients who were started on VIP more than 5 years ago, between November 1984 and July 1989. The hospital records and data from the 100 responders (93%) were reviewed. RESULTS: Only 32% of the patients continue to use VIP. Most (56%) of those who discontinued did so during the first year. The patients cited one or more of the following reasons for discontinuation: desire for a permanent modality of therapy (29%), lack of a suitable partner (26%), fear of needles (23%), poor response (23%), fear of complications (22%), and lack of sexual spontaneity (21%). This study, which has one of the longest follow-up periods in the literature, has significant new findings in three areas: discontinuation rates fall after 2 years, long-term complications are relatively minor, and patients who discontinue therapy are significantly older or have a poor initial impression of VIP. Paradoxically, discontinuing VIP was apparently unrelated to side effects or etiology of erectile dysfunction, and 82% of patients would still recommend VIP to a friend. CONCLUSIONS: This study conclusively shows that because of high initial satisfaction and relatively minor side effects, VIP should remain as one of the initial options for long-term treatment of erectile dysfunction. However, despite seemingly doing well, patients often discontinue therapy, and therefore should be followed closely so that alternative therapy can be offered.

Clinical trial of a simplified vacuum erection device for impotence treatment.

Thirty-one men participated in a clinical trial of a simplified vacuum erection device (Catalyst) in which the pump and penile cylinder have been combined to facilitate the pumping required to induce a vacuum. Of the 28 men who completed the three-month trial, 26 (93%) reported overall satisfaction with the device and an intention to continue its use, and 2 men were unable to maintain a satisfactory erection. Episodes of mild bruising or development of petechiae occurred in 9 men. None of the complications required treatment or prevented safe use of the device. Our experience with this new vacuum device indicates a high degree of patient satisfaction and minimal complications. On average, patients rated ease of use high at all follow-up visits.

Transurethral resection of prostate immediately after renal transplantation.

The subject of transurethral resection of the prostate (TURP) after renal transplantation has not been evaluated in the urologic literature. We retrospectively compared the outcome of renal transplantation in 8 patients who underwent transurethral resection of the prostate within ten days of renal transplantation with 8 patients who did not undergo prostate surgery. Patients were computer-matched for seven parameters. There was no statistically significant difference in patient survival (6 vs 7) and graft survival (56% vs 88%) between the two groups. However, there was a 25 percent incidence of major perioperative complications (including one mortality) in the TURP group directly attributable to the procedure. Transurethral resection of the prostate can be safely performed immediately after renal transplantation only if urine is sterile, antibiotics and steroids are carefully administered perioperatively, low-gravity irrigation is used, and hemostasis is meticulous.

Long-term followup results after expectant management of stage A1 prostatic cancer.

A total of 132 patients with stage A1 adenocarcinoma of the prostate was followed for 5 to 23 years (mean 8.2 years). Of these patients 52 underwent a second staging transurethral resection of the prostate between 1977 and 1986. Progressive disease developed in 3 of the 12 patients (25%) in whom residual foci of well differentiated cancer were detected by the second transurethral resection and who did not undergo further treatment. Of the 38 patients in whom the second transurethral resection did not detect residual cancer 3 (8%) also had progressive disease. From April 1989 to December 1989, 44 patients were re-evaluated by transrectal ultrasonography and ultrasonographically guided biopsies. Of these patients 3 had locally progressive disease. Progressive disease also developed in 4 more patients. Thus, 13 of the 132 patients (10%) had either locally or systemically progressive disease after long-term followup. The interval from diagnosis of stage A1 disease to detection of progression ranged from 6 months to 20 years (mean 7 years). Ten patients underwent definitive treatment for what was believed to be locally progressive disease, 2 underwent palliative therapy and 1 had no therapy due to poor physical condition. Of the 10 patients who underwent definitive therapy 6 are alive without evidence of disease, 2 died of unrelated causes without evidence of disease and 2 are alive with stage D1 disease. These data suggest that patients in whom a second staging transurethral resection of the prostate detects residual cancer have a high probability of progressive disease. Also, negative findings from a second staging transurethral resection may not exclude the possibility of disease progression. Expectant management of stage A1 disease is warranted but regular and long-term followup is mandatory.

Patient acceptance of and satisfaction with an external negative pressure device for impotence.

Patient acceptance of and satisfaction with an external negative pressure device as a treatment for impotence were retrospectively analyzed among 100 men. The over-all satisfaction rate was 68%. Reasons for dissatisfaction with and discontinuing the use of the device included premature loss of penile tumescence and rigidity, pain or discomfort either during application of suction or during intercourse and inconvenience. Negative pressure therapy is an effective treatment for impotence of various etiologies and should be among treatment options offered to the impotent patient.

Endoscopic ureteral occlusion for urinary diversion in patients with lower urinary tract fistulas.

Endoscopic ureteral occlusion and nephrostomy drainage is a simple, nonsurgical procedure that can control urine leakage from an intractable lower urinary tract fistula and improve the quality of life for a patient with a short life expectancy.

Modified stirrups for dorsal lithotomy positioning.

The modified dorsal lithotomy position is excellent for radical pelvic operations. Use of modified Krauss arm supports as stirrups, along with pneumatic devices that intermittently compress the legs, significantly reduces postoperative morbidity in patients who undergo operations in this position.

Simplified tourniquet for intracavernous pharmacotherapy.

A simplified tourniquet, the Barretta Laso, is described for use during intracavernous injection of vasoactive drugs. The advantages of this device over current tourniquet methods include simple application; easy control of the degree of constriction; and quick, single-handed release.

Treatment of detrusor-sphincter dyssynergia with botulinum A toxin: a double-blind study.

The ability of botulinum A toxin to denervate and relax a spastic external urethral sphincter was evaluated in a double-blind study involving five men with high spinal cord injuries and detrusor-sphincter dyssynergia. The sphincter was injected with either a low dose of botulinum A toxin or normal saline once per week for three weeks. Electromyography of the external urethral sphincter indicated denervation in the three patients who received toxin injections. The urethral pressure profile decreased an average of 25cm of water, postvoiding residual volume of urine decreased an average of 125cc, and bladder pressure during voiding decreased to an average of 30cm of water. Bulbosphincteric reflexes were more difficult to obtain, and they showed a decreased amplitude with normal latency. In the two patients who received normal saline injections, parameters were unchanged from baseline values until subsequent injection with botulinum A toxin once per week for three weeks when their responses were similar to those of the other three patients. Mild generalized weakness lasting two to three weeks was noted by three patients after initial toxin injections. The duration of the toxin's effect averaged two months. The results suggest that botulinum A toxin, an inhibitor of acetylcholine release at the neuromuscular junction, may be useful in the treatment of detrusor-sphincter dyssynergia.

Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients.

A total of 12 spinal cord injury adults underwent augmentation enterocystoplasty for treatment of a high pressure neurogenic bladder. These patients suffered from urinary incontinence, recurrent urinary tract infection, upper tract deterioration and severe autonomic dysreflexia. A sigmoid colon segment fashioned into a cup-patch was used in 11 patients and detubularized cecum was used in 1. The artificial urinary sphincter was implanted in 3 patients at augmentation enterocystoplasty and in 1 after enterocystoplasty. After a mean followup of 15 months all patients were continent on clean intermittent self-catheterization, the upper tract had remained stable or had improved and the symptoms of autonomic dysreflexia had disappeared. A third of the patients are on maintenance antibiotic therapy to control bacteriuria.

Urethral false passage as a complication of intermittent catheterization.

Intermittent catheterization is used commonly to treat bladder dysfunction. We treated 10 patients who were experiencing difficulty with intermittent catheterization, 9 of whom had a false urethral passage. Of these patients 6 had previously undergone a bladder neck or urethral operation. Endoscopy was helpful to diagnose the condition. Treatment consisted of stenting in 3 patients, transurethral incision and stenting in 3, and fulguration and stenting in 4. An indwelling catheter was left in place for 2 to 3 weeks, after which intermittent catheterization was resumed with a softer catheter. Two patients again experienced severe difficulty with catheterization and they underwent a continent urinary diversion. When intermittent catheterization becomes difficult or impossible, the presence of a urethral false passage should be suspected as a possible cause.

Compatibility of enterocystoplasty and the artificial urinary sphincter.

Placement of the artificial urinary sphincter during augmentation enterocystoplasty may lead to infection, erosion and eventual removal of the device. To assess compatibility of artificial urinary sphincter implantation and enterocystoplasty we reviewed the records of 30 patients who had undergone enterocystoplasty and artificial urinary sphincter placement simultaneously (11), enterocystoplasty before artificial urinary sphincter placement (12) and artificial urinary sphincter placement before enterocystoplasty (7). The 19 male and 11 female patients were between 4 and 42 years old (median age 13.5 years). Followup in 28 patients ranged from 6 months to 8 years (average 17 months). Incontinence resulted from myelodysplasia in 16 patients, sacral agenesis in 3, spinal cord injury in 6, posterior urethral valves in 1, bilateral ectopic ureters in 1 and epispadias-exstrophy in 3. Erosion occurred in 2 patients (7 per cent): 1 female patient who underwent simultaneous sphincter implantation and enterocystoplasty and who had undergone previously many bladder neck reconstructive procedures, including polytetrafluoroethylene (Teflon) injection, and 1 female patient in whom the augmented bladder was entered at artificial urinary sphincter implantation. Mechanical failure occurred 4 times in 3 patients and the artificial urinary sphincter was improperly placed in 1. Over-all continence rate was 87 per cent (26 of 30 patients). Simultaneous placement of the artificial urinary sphincter and enterocystoplasty did not seem to affect the outcome of sphincter implantation if good bowel preparation, intravenous antibiotics and sterility of urine were accomplished preoperatively. Entering the augmented bladder during sphincter implantation may predispose to infection and erosion.

The artificial sphincter AS800 in congenital urinary incontinence.

The artificial urinary sphincter AS800 was implanted in 33 male and 13 female patients with congenital urinary tract incontinence. In 15 patients (32 per cent) previous operations to correct incontinence had failed. The sphincter was implanted around the bladder neck in 43 patients and around the bulbous urethra in 3. Mean patient age at the time of sphincter implantation was 13 years. In 40 patients (87 per cent) the sphincter functions well after a mean followup of 25 months and 39 patients (85 per cent) have satisfactory continence. In 6 patients the sphincter was removed because urethral, vulvar or scrotal erosions developed, all of whom had had previous surgical procedures in the area of the erosion. In 1 patient not operated upon previously erosion of the bulbous urethra developed. He did well after a new sphincter was implanted around the bladder neck. Five patients required an enterocystoplasty to achieve continence following the sphincter implantation. Nine patients required surgical revision of the sphincter for mechanical failure, technical errors, trauma and patient growth. We conclude that in patients with neurogenic sphincter failure implantation of an artificial sphincter around the bladder neck should be considered as the initial treatment of choice.

Patient acceptance of and satisfaction with vasoactive intracavernous pharmacotherapy for impotence.

Patient acceptance of and satisfaction with a trial of vasoactive intracavernous pharmacotherapy for impotence among 372 men were retrospectively analyzed. Drop out from the dosage determination phase and the training for injection phase was similar, 9.7 and 8.4 per cent, respectively, while 31.4 per cent of the patients dropped out of the home injection phase. Tachyphylaxis, inconvenience of the procedure or the frequent followup visits required, side effects and concern about unknown long-term effects were the main reasons patients cited for dropping out of the trial. The degree of satisfaction among patients who entered the home injection phase was high. Only 55 patients who dropped out of the trial chose implantation of a penile prosthesis. Vasoactive intracavernous pharmacotherapy is an effective treatment for impotence of various etiologies, and in a carefully selected group of patients the acceptance of and satisfaction with this therapy are high.