Continence after radical cystoprostatectomy and total bladder replacement: a urodynamic analysis.

Urodynamic evaluation was performed in 10 patients after radical cystoprostatectomy and continent urethral diversion with detubularized ileum and in 13 patients continent after radical prostatectomy. In both groups surgical techniques were modified to optimize preservation of the periurethral tissue at the prostatic apex. For the ileal neobladder group 9 patients (90%) were completely continent and 1 (10%) noticed moderate nocturnal incontinence. The urethral sphincteric mechanism was well preserved in these patients, with no significant difference between the 2 groups in mean functional urethral length (3.8 +/- 0.6 versus 3.6 +/- 0.8 cm., p = 0.55) or maximal urethral closure pressure (87 +/- 34 versus 74 +/- 20 cm. water, p = 0.26). Tubularization of the bladder or neobladder above the level of the external sphincter was noted in both groups. Continence after radical cystoprostatectomy with continent urethral diversion and after radical prostatectomy is dependent upon an intact urethral sphincteric mechanism as well as a compliant, low pressure reservoir, either bladder or a bladder substitute. Urinary incontinence after total bladder replacement with detubularized ileum can be minimized by preserving as much of the distal urethral sphincter as possible. This can be done by careful dissection of the prostatic apex, performed under direct vision, with an understanding of the anatomy of the urethral sphincter and its innervation.

The blood supply to preputial island flaps.

The prepuce is formed by a combination of folding and epithelial proliferation, and separates from the glans after it has developed a blood supply. The arterial input, through 4 branches from the external pudendal arteries, is terminal and after birth supplies the outer and inner preputial surfaces in succession. Similarly, the venous return arises from small veins running transversely in the prepuce that connect to larger subcutaneous veins along the dorsal aspect of the shaft. Because the 2 preputial surfaces have a single blood supply they must be treated as 1 unit. Unfolding the prepuce leaves the former inner segment with only a terminal blood supply. The pedicle containing the superficial blood supply must remain attached to the skin flap or it will be devascularized. However, since this circulation goes exclusively to the flap, the more proximal portion of the prepuce that was raised to form the pedicle becomes ischemic when used as ventral cover. A double-faced flap avoids this complication.

The value of screening for prostatic carcinoma: a commentary.

Can routine digital rectal examinations, transrectal ultrasound studies, and prostate-specific antigen determinations reduce deaths from prostatic carcinoma? The evidence is that the benefits of early diagnosis and treatment are at least neutralized by the limited reliability and high monetary and human costs of the test and by the lack of proof that treatment is effective for those tumors detected. One must conclude that universal screening is not now warranted and will await demonstration of effectiveness by controlled studies.

Screening for prostatic carcinoma.

Routine testing for prostatic carcinoma by digital rectal examination, transrectal ultrasonography and prostate specific antigen determination has been proposed to reduce deaths by earlier diagnosis. The questionable reliability of results, cost of screening, and inability to establish a balance between the benefits of treatment and the adverse effects on the quality of life of the men screened make screening experimental until controlled studies prove its value.

Functional classification of conduits for continent diversion.

To facilitate rational surgical application of conduits leading from intestinal reservoirs, the mechanisms that maintain continence are classified and illustrated with 4 hydrodynamic principles: 1) sphincteric compression, achieved by decreasing the caliber of the conduit, 2) peristalsis, which conducts urine toward the reservoir, 3) equilibration of inside and outside pressure as gained by nipple formation or construction of a chamber, and 4) the flap valve principle, with configurations similar to those of ureteroneocystostomy. An additional contribution to continence comes from the seal produced by the inner softness of the mucosa.

Subspecialization and general urology.

Subspecialization within urology is growing, affecting not only teaching and research but the general practice of urology as well. To evaluate present attitudes towards subspecialization a questionnaire was sent to the membership of the Western Section of the American Urological Association. The responses from 561 members (53 per cent) were tabulated by computer and analyzed. Of those in private practice 16 per cent consider themselves to be subspecialists, although half of these have had no formal training. More subspecialize in oncology, andrology and gynecology than in pediatric urology. Opinions toward issuing certificates of special competence are mixed but opposition to board certification is general. A majority of respondents believe that subspecialization might provide better care for some patients but would increase costs, especially for tertiary care. It would not result in inferior care for patients not having access to the subspecialist. Subspecialization would be expected to reduce the economic return to the nonspecialist without increasing it for the specialist. Respondents believe that it would advance diagnosis, treatment and research in special areas, and improve training and competence but at greater expense. Finally, they express concern that subspecialization may well restrict the experience and competence of general urologists and cause conflict.