A modified percutaneous outpatient bladder neck suspension system.

During the last 8 years the original percutaneous needle suspension of Pereyra has been enhanced with the goal to reestablish safely and simply support of the pubocervical fascia in a reproducible and secure manner. Refinements include changes in points of suture attachment, limitation of suture tension and devices to perform the procedure simply and anchor the suspending suture in bone. A path along 2 planes of landmarks is used to guide the needle in capturing a maximum amount of mobile pubocervical fascia with a minimum risk of injury to the bladder or ureter. In 3 years over 150 patients have undergone this procedure. Early problems included suture breakage and inaccurate anchor placement. There have been no cases of chronic urinary retention. During the last 2 years the procedure has been performed on an outpatient basis. When suprapubic infection has been suspected, symptoms and signs have resolved with antibiotics. No sutures have been removed and osteitis pubis has not been noted. Any improvement in long-term durability has not yet been determined due to the history of ongoing refinements and the need for subsequent long-term followup. The specifics of this suspension system are described.

Anchor fixation and other modifications of endoscopic bladder neck suspension.

The long-term efficacy of surgical treatment of stress urinary incontinence can be improved by modifications that reduce the possibility of suspending suture detachment. Fifty-three women with stress urinary incontinence underwent consecutive endoscopic bladder neck suspensions with new modifications developed in an effort to decrease suspending suture detachment. Those modifications included: (1) technique of needle passage to capture a maximum volume of urethropelvic fascia lateral to the bladder neck and urethra while avoiding injury to the bladder, (2) pubic bone fixation of the suspending suture using a small anchor developed for orthopedic use, and (3) a simple technique to limit tension of the suspending sutures. Procedures were outpatient in 60 percent of patients (93% of the last 27 patients). Seventy percent of patients did not require intermittent catheterization beyond the day when their indwelling catheter was removed. The postoperative success rate (absence of stress urinary incontinence) at one month was 100 percent. There were 4 failures on follow-up up to fifteen months. Urgency incontinence decreased from 59 percent preoperatively to 15 percent postoperatively. The complication of osteitis pubis was not noted. Patient rating of satisfaction postoperatively was high. These modifications constitute a safe alternative to procedures that effectively suspend the bladder neck. An assessment of any change in long-term efficacy as a result of these modifications will require continued follow-up.

Preservation of penile length in penile cancer and trauma by use of a pedicled flap.

A surgical technique is described for the treatment of carcinoma and injury involving the distal penile shaft in which a standard partial penectomy would leave inadequate penile length for satisfactory voiding. As an alternative to standard total penectomy with perineal urethrostomy that is used in this situation, partial penectomy is performed and a flap of suprapubic and scrotal skin is rolled into a new proximal penile shaft covering. This technique offers the patient the advantage of voiding in the standing position with a penile stump, and the possibility for sexual satisfaction and less physical disfigurement.

Acetylcysteine for urinary tract mucolysis.

The use of acetylcysteine is described for the relief of mucinous obstruction of the distal ureter after a mid ureteral replacement with ileum. Acetylcysteine (300 cc of 1 per cent) was instilled at low pressure via a nephrostomy tube following documentation of the obstruction with a nephrostogram. Patency of the ureter was achieved within 5 minutes. Re-obstruction ensued but it resolved with repeat percutaneous instillation of acetylcysteine. Patency, confirmed by a followup nuclear renogram at 4 months, has been maintained with 700 mg. acetylcysteine orally 4 times a day.

Dosimetry study of Nd:YAG laser damage to canine renal cortex.

A dosimetry study of factors affecting the extent of tissue damage inflicted upon the canine renal cortex by the Neodymium:Yttrium Aluminum Garnet (Nd:YAG) laser was undertaken. Laser parameters and renal tissue conditions were varied independently in duplicate in the following manner: (1) power - 5, 10, 20, 50, 75, 100 watts with a spot size of 1.2 mm; (2) exposure duration - 1, 2, and 4 seconds; (3) kidney perfusion and temperature--renal artery unclamped (perfused) without cooling; renal artery clamped (non-perfused) without cooling; and renal artery clamped with cooling. Five days following application of the laser, the animals were sacrificed and serial sections of the renal cortex were examined for maximum depth and width of tissue damage and ablation. Multiple linear regression analysis of the data indicated a direct linear relationship between the joules (watts X seconds) of energy delivered to the renal cortex and the depth and width of tissue damage and ablation (p less than 0.001 for joule regression coefficient for each variable). Seconds and/or watts alone were not major predictors of the outcome after accounting for joules. Clamping the main renal artery significantly reduced the depth and width of laser damage when compared to the perfused kidney (p less than 0.001 for each variable). The depth of damage was similar in the cooled and the non-cooled non-perfused kidney. These data suggest that increased laser energy and kidney perfusion significantly increase renal cortical laser induced damage. Adjustment of these parameters may permit controlled tumor ablation or tissue incision with minimal damage to adjacent normal tissue.

Inferior vena cava obstruction secondary to adenocarcinoma of the prostate. Role of orchiectomy in treatment.

We describe a patient with a radiologically verified inferior vena cava obstruction due to metastatic adenocarcinoma of the prostate who was treated by orchiectomy. The prompt regression of the disease causing the obstruction confirms that orchiectomy alone can be an effective treatment of massive, functionally significant metastatic carcinoma of the prostate.

Efficacy and safety of the Nd:YAG laser in canine partial nephrectomy.

Partial nephrectomy using 100 watts of focused Neodymium: Yttrium Aluminum Garnet (Nd:YAG) laser power was evaluated to determine its hemostatic capabilities, safety, and effect on renal function and histology. Six adult female dogs ranging from 22 to 33 lbs. underwent nephrectomy and contralateral partial nephrectomy using the laser. Closure of the collecting system and drains were not used to determine if the laser could seal the collecting system. There was no blood loss with this technique. Four of the 6 dogs had no postoperative complications but two had urinary extravasation which led to death in one dog and required drainage in another. One month postoperative serum creatinine levels were 66 per cent higher than pre-operative values. Intravenous urograms revealed no evidence of dilation of the collecting system nor contrast extravasation. The depth of necrosis ranged from 4 mm. in the cortex to 7 mm. in the medulla. The data indicate that Nd:YAG laser partial nephrectomy is effective, and provides complete hemostasis, manageable urinary extravasation and acceptable impairment of renal function.

Preliminary study of the Nd:YAG laser in canine partial nephrectomy.

Partial nephrectomy is effective in the treatment of segmental renal disease but hemostasis remains a challenge. In this preliminary investigation the Nd:YAG laser was used alone or as an adjunct to the scalpel in partial nephrectomies to determine if hemostasis could be improved. A technique of 100-W laser transection with occlusion of the renal artery was effective for partial nephrectomy and achieved complete hemostasis. Conditions of patent renal artery flow or renal cooling were associated with a reduction in necrosis depth with 100-W laser partial nephrectomies. All techniques were compatible with survival over the 5-day study period.