Orthotopic bladder substitution in men revisited: identification of continence predictors.

PURPOSE: We determined the impact of the functional characteristics of the neobladder and urethral sphincter on continence results, and determined the most significant predictors of continence. MATERIALS AND METHODS: A total of 88 male patients 29 to 70 years old underwent orthotopic bladder substitution with tubularized ileocecal segment (40) and detubularized sigmoid (25) or ileum (23). Uroflowmetry, cystometry and urethral pressure profilometry were performed at 13 to 36 months (mean 19) postoperatively. The correlation between urinary continence and 28 urodynamic variables was assessed. Parameters that correlated significantly with continence were entered into a multivariate analysis using a logistic regression model to determine the most significant predictors of continence. RESULTS: Maximum urethral closure pressure was the only parameter that showed a statistically significant correlation with diurnal continence. Nocturnal continence had not only a statistically significant positive correlation with maximum urethral closure pressure, but also statistically significant negative correlations with maximum contraction amplitude, and baseline pressure at mid and maximum capacity. Three of these 4 parameters, including maximum urethral closure pressure, maximum contraction amplitude and baseline pressure at mid capacity, proved to be significant predictors of continence on multivariate analysis. CONCLUSIONS: While daytime continence is determined by maximum urethral closure pressure, during the night it is the net result of 2 forces that have about equal influence but in opposite directions, that is maximum urethral closure pressure vs maximum contraction amplitude plus baseline pressure at mid capacity. Two equations were derived from the logistic regression model to predict the probability of continence after orthotopic bladder substitution, including Z1 (diurnal) = 0.605 + 0.0085 maximum urethral closure pressure and Z2 (nocturnal) = 0.841 + 0.01 [maximum urethral closure pressure - (maximum contraction amplitude + baseline pressure at mid capacity)].

Mechanism of continence after repair of post-traumatic posterior urethral strictures.

OBJECTIVES: To determine the mechanism of urinary continence after repair of post-traumatic posterior urethral strictures by perineal anastomotic urethroplasty. METHODS: Two groups of male patients were enrolled in this study. Group 1 consisted of 8 patients (mean age 31 years) who had undergone bulboprostatic anastomotic urethroplasty for strictures complicating a pelvic fracture urethral disruption. Group 2 consisted of 8 patients (mean age 32.5 years) with a normal urethra who were used as controls. All 16 patients underwent urethral pressure profilometry both at rest and with cough and hold maneuvers. RESULTS: In group I, urethral pressure profilometry showed much lower mean maximal urethral pressures and maximal urethral closure pressures, as well as a much shorter mean functional profile length than in group 2 (48 and 39 cm H(2)O versus 75 and 65 cm H(2)O and 2.4 versus 4 cm, respectively, P <0.0003). On cough maneuver, intra-abdominal pressure changes were transmitted along the entire functional profile length in group 1 and only along its first part in group 2. The hold maneuver increased urethral pressure in 5 patients (65%) in group 1 and in all 8 patients (100%) in group 2. CONCLUSIONS: Continence after anastomotic urethroplasty for post-traumatic posterior urethral strictures is maintained solely by the proximal urethral mechanism. Transmission of intra-abdominal pressure changes and contraction of pelvic floor musculature may augment urethral closure in these cases during stress conditions.

Pelvic fracture urethral injuries: the unresolved controversy.

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.

Micturition after gastrocystoplasty and gastric bladder replacement.

PURPOSE: We determine the function of gastric tissue as a reservoir for urine and driving force for urination. MATERIALS AND METHODS: A total of 12 men 15 to 45 years old underwent gastrocystoplasty (8) or gastric bladder replacement (4). In 1 patient bladder neck reconstruction was performed with augmentation using the same gastric segment. Ten patients were followed for 1 to 2 years, and evaluated subjectively and objectively, including a urodynamic study 6 months postoperatively. RESULTS: No patient had dysuria or hematuria, despite urinary pH of 5 or less. Mean bladder capacity after augmentation increased from 130 (range 60 to 150) to 420 ml. (range 400 to 470), and was 350 ml. (range 340 to 380) after gastric replacement. Uninhibited contractions occurred only when bladder filling reached 71 to 92% of ultimate capacity with a mean amplitude of 22 cm. water (range 5 to 38). Patients with a gastric neobladder demonstrated an interrupted biphasic flow pattern with a mean maximum flow rate of 12 ml. per second (range 11.5 to 12.8). Urine was evacuated mainly by contraction of the gastric bladder (74%) in stage 1 and by abdominal straining (80%) in stage 2 of voiding. CONCLUSIONS: Stomach seems to be an ideal source of material for bladder augmentation or replacement. The high capacity, low pressure reservoir provided by gastric tissue is probably due to the nature of the involuntary contractions, which occur only late in filling with a low amplitude. Also, the gastric neobladder is evacuated mainly by contraction of its musculature, supplemented with abdominal straining at the end of voiding.

Posttraumatic posterior urethral strictures in children: a 20-year experience.

PURPOSE: We attempted to identify the particular features of strictures complicating pelvic fracture urethral injuries in children. MATERIALS AND METHODS: A total of 68 boys 3 to 15 years old who had sustained pelvic fracture urethral disruption underwent 78 urethroplasties performed by bulboprostatic anastomosis through the perineum in 42, transpubically in 23 and by 2-stage urethroscrotal inlay in 13. RESULTS: Perineal and transurethral urethroplasty was successful in 93 and 91% of cases respectively. There was a 54% failure rate after urethroscrotal inlay. CONCLUSIONS: Urethral strictures were most commonly associated with Malgaigne's fracture (35% of cases) and straddle fracture with or without diastasis of the sacroiliac joint (26%). Strictures were almost invariably inferior to the verumontanum with prostatic displacement in 44% of cases. Length of the strictured segment may be overestimated or underestimated on urethrography as a result of incomplete filling of the prostatic urethra or a urinoma cavity connected with the proximal segment, respectively. Perineal or transpubic bulboprostatic anastomosis is the best treatment for posttraumatic strictures, while internal urethrotomy should be avoided since it may compromise the chance of subsequent anastomotic urethroplasty. Repair of associated bladder neck incompetence may be deferred until the resumption of urethral voiding after urethroplasty, when incontinence can be documented.

Pelvic fracture urethral injuries: evaluation of various methods of management.

PURPOSE: The results of various immediate treatments of urethral injuries complicating a fractured pelvis were evaluated. MATERIALS AND METHODS: The records of 100 male patients with pelvic fracture urethral injury were reviewed, 73 of whom were treated by suprapubic cystostomy and delayed repair, 23 by primary realignment and 4 by primary suturing. Also, the findings of 771 patients reported in the literature were reviewed. RESULTS: Urethral stricture was an almost inevitable consequence (97% of the cases) after suprapubic cystostomy. Primary realignment decreased the incidence of stricture to 53% but produced a 36% impotence rate. Primary suturing also decreased the incidence of stricture to 49% but produced the greatest complication rates for impotence (56%) and incontinence (21%). CONCLUSIONS: Suprapubic cystostomy alone is indicated for incomplete urethral rupture, slight urethral distraction and critically unstable patients, and when there are inadequate facilities or inexperienced surgeons. Primary realignment is advised if there is wide separation of the urethral ends, or associated injury of the bladder neck or rectum. Primary suturing is not recommended for any condition.

Impact of the prostatic apex on continence and urinary flow in patients with intestinal neobladders.

OBJECTIVE: To determine the impact of preserving the prostatic apex on continence and urinary flow in patients with post-cystectomy intestinal bladder substitutes. PATIENTS AND METHODS: A total of 38 male patients underwent radical cystectomy for bladder carcinoma and construction of a neobladder from ileum [9], sigmoid [9] or an ileocaecal segment [20]. The intestinal reservoir was anastomosed to the membranous urethra in 25 patients and to the apical prostatic capsule in 13. A subjective evaluation of urinary continence, uroflowmetry and urethral pressure profilometry were performed 1-3 years after surgery. RESULTS: The only variable which showed a significant difference between patients with and without preservation of the prostatic apex was the functional profile length (P < 0.05). Conversely, there was no statistically significant difference in the continence result, peak flow rate and maximum urethral pressure between these two groups. However, there was a significant difference (P < 0.05) in peak flow rate among the three versions of neobladder in patients with a preserved prostatic apex (9.4 mL/s in ileal vs 15.8 mL/s in sigmoid and ileocaecal segments). CONCLUSION: Preservation of the prostatic apex does not improve urinary continence in patients with intestinal neobladders and may present an element obstructing the evacuation of ileal bladders.

Risk factors and mechanism of urethral injury in pelvic fractures.

OBJECTIVE: To determine the risk factors and mechanism of urethral injury associated with pelvic fractures. PATIENTS AND METHODS: A total of 203 consecutive male patients with pelvic fracture were studied prospectively, including a clinical examination, radiographic examination of the pelvis, excretory urography and retrograde urethrography. RESULTS: Thirty-nine (19%) patients had urethral injury, five (2.5%) had bladder injury and 12 (6%) had combined urethral and bladder injuries. Urethral injury was by stretching of the intact membranous urethra in 13 patients (25.5%), partial rupture in 13 (25.5%) and complete rupture in 25 (49%). Injury involved the prostatic urethra and bladder neck in three children. Urethral injury was consistently associated with pubic arch fractures. Involvement of the posterior pelvic arch, with fractures of the anterior arch, considerably increased the risk of urethral injury. Also, the risk was greater with an increase in the number of broken rami. CONCLUSION: The highest risk of urethral injury was found in cases with straddle fracture when combined with diastasis of the sacroiliac joint (24 times more than the rest of pelvic fractures); this was followed by straddle fracture alone (3.85 times) and Malgaigne's fracture (3.4 times). Stretching of the membranous urethra usually precedes its rupture, which classically occurs at the bulbomembranous junction.

Desire to void and force of micturition in patients with intestinal bladders.

PURPOSE: We attempted to determine how patients with an orthotopic bladder perceive the desire to void and the force achieved to evacuate the bladder. MATERIALS AND METHODS: A total of 24 men who had undergone post-cystectomy bladder substitution (ileocecal in 12, sigmoid in 6 and ileal in 6) was evaluated subjectively an objectively by pressure-flow study 1 to 3 years postoperatively. RESULTS: Desire to void was felt at the base of the penis or in the perineum by 20 men (83%). Abdominal pressure contributed to intra-reservoir pressure by 51 to 54% in ileocecal, 20 to 24% in sigmoid and 23 to 25% in ileal neobladders. CONCLUSIONS: Patients perceive the desire to void when drops of urine leak into the proximal urethra from an overfilled neobladder. Urine is evacuated mainly by abdominal straining for ileal neobladders, mainly by contraction for sigmoid neobladders, and by approximately equal contributions of contradiction and straining for ileocecal neobladders.

Early and late cystometry of detubularized and nondetubularized intestinal neobladders: new observations and physiological correlates.

PURPOSE: We studied the volume and pressure changes with time in detubularized and nondetubularized neobladders. MATERIALS AND METHODS: Cystometry was performed at early and late followup in 54 male patients with post-cystectomy intestinal neobladders constructed from an intact ileocecal segment in 33, detubularized sigmoid in 11 and detubularized ileum in 10. RESULTS: With time the capacity of the neobladder increased in all 3 groups. Concomitantly, while intact ileocecal bladders showed an increase in intra-reservoir pressure and persistence of involuntary contractions, detubularized sigmoid and ileal bladders showed a decrease in intra-reservoir pressure and involuntary contractions. CONCLUSIONS: Increased capacity with time is not due to detubularization per se but rather to over distension, which is more marked in detubularized (109 to 112%) than in tubular (79%) segments. Detubularized intestinal neobladders not only offer a high capacity, low pressure and high compliant reservoir but these characteristics also are increased with time.

Changing age incidence and pathological types of schistosoma-associated bladder carcinoma.

PURPOSE: The changes in certain characteristic features of schistosoma-associated bladder carcinoma are determined. MATERIALS AND METHODS: A retrospective study was done of patients with schistosoma-associated bladder carcinoma treated between 1962 and 1967, and between 1987 and 1992. RESULTS: Mean patient age increased from 47 +/- 13.6 to 53 +/- 12.2 years and the male-to-female ratio changed from 7.8:1 to 4.9:1. Tumors showed a decreased incidence of nodular (58.7% versus 83.4%) and squamous (54% versus 65.8%) cell types, and an increased incidence of papillary (34.8% versus 4.3%) and transitional (42% versus 31%) cell types. All changes were statistically significant (p < 0.05) and paralleled by an increased incidence of low degree schistosomal infestation from 18.6 to 47.8% (p < 0.05). CONCLUSIONS: The shift in age incidence and pathological findings towards those of nonschistosomal cases could conceivably be attributed to the increased incidence of low infestation in recent years. The change in male-to-female ratio is probably due to more exposure of women to schistosomal infestation than has occurred previously.

The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years.

We reviewed our experience with 145 posterior urethral strictures and disruptions complicating pelvic fracture urethral injury during 17 years. Stricture was corrected by optical urethrotomy in 12 cases, urethroscrotal inlay in 23, perineal anastomotic urethroplasty in 78 and transpubic urethroplasty in 32. Results were almost always successful after anastomotic urethroplasty, whether performed by the perineal (95%) or transpubic (97%) route. Therefore, this procedure deserves to be regarded as the gold standard for the treatment of posttraumatic posterior urethral strictures and disruptions. Urethral anastomosis should be attempted first through the perineum in every case, with the transpubic procedure done only when a tension-free bulbo-prostatic anastomosis could not be accomplished from below the stricture. Optical urethrotomy was successful (58%) in patients with mild strictures and a persistent opening between the bulbar and prostatic areas of the intact urethra. Therefore, this procedure should be reserved for such cases. Repeated urethrotomy of a long fibrous segment between a widely distracted prostatic and bulbar urethra would not only have a poor result but, by jeopardizing the elasticity of the anterior urethra, it also may undermine the chance for subsequent anastomotic urethroplasty. A urethroscrotal inlay procedure is doomed to failure in 57% of the cases and (with other substitution procedures) it should be restricted to strictures involving extensive segments of the posterior and/or anterior urethra. Sexual impotence usually (15%) resulted from the original pelvic fracture urethral injury and rarely (2.5%) from the urethroplasty itself.