Multiple sclerosis and the urologist.

PURPOSE: We provide an updated reference detailing the neurological and urological state of the art approach to multiple sclerosis (MS) with special emphasis on the pathology and physiology, effects on the genitourinary tract, diagnostic evaluation, and treatment of neurological and urological manifestations. MATERIALS AND METHODS: A MEDLINE computerized reference search and manual bibliography review were performed to find pertinent peer reviewed articles on the neurological and urological manifestations and treatment of MS. A meta-analysis was performed on the urodynamic findings of 22 studies involving 1,882 patients from well-defined MS populations. RESULTS: The majority of patients with MS have genitourinary symptoms ranging from urgency, urge incontinence and frequency to urinary retention. Symptoms do not accurately reflect the underlying urological pathology but parallel pyramidal tract dysfunction. Urodynamic evaluation has an important role in determining proper bladder management. The most common urodynamic finding is detrusor hyperreflexia in 62% of these patients, followed by detrusor-sphincter dyssynergia in 25% and hypocontractility in 20%. Less than 1% of patients has renal deterioration and most may be treated with conservative measures. If conservative measures fail, new forms of bladder reconstruction and diversion may be effectively used. The incidence of sexual dysfunction is up to 80% in men and 72% in women, and treatment focuses on improvement of overall disability and erectile or orgasmic function. CONCLUSIONS: Although the genitourinary consequences of MS are rarely life threatening, they can cause significant morbidity and patient frustration. With the rapid advances in the medical management of MS the urologist should be actively involved in multispecialty treatment of these patients.

Vaginal wall sling: long-term outcome analysis of factors contributing to patients satisfaction and surgical success.

PURPOSE: The clinical outcome of the vaginal wall sling was retrospectively evaluated to determine patient perception, satisfaction and factors contributing to postoperative success. MATERIAL AND METHODS: An outcome based study was conducted of 51 patients undergoing construction of a vaginal wall sling for genuine stress incontinence or intrinsic sphincteric deficiency. Preoperative symptoms, demographic parameters and video urodynamic studies were correlated with postoperative patient perception of symptoms to determine patient satisfaction and factors contributing to overall success. RESULTS: Of 42 patients (82%) available for followup 31 (74%) reported improvement in continence, 26 (62%) are currently satisfied with the urinary status, 72% in retrospect would repeat the procedure and 69% would recommended the vaginal wall sling to others. Despite long-term resolution of stress incontinence in 92% of those with genuine stress incontinence and 75% with intrinsic sphincter deficiency, postoperative urge incontinence was the single most important factor affecting patient satisfaction (p = 0.001). Patients without postoperative urge incontinence enjoyed the greatest levels of satisfaction, in excess of 90% (p = 0.001). Although preoperative leak point pressure correlated with resolution of stress incontinence, no preoperative demographic factors, symptoms or urodynamic parameters could reliably predict postoperative patients satisfaction. CONCLUSIONS: The vaginal wall sling represents an excellent option for the treatment of genuine stress incontinence and an acceptable option of intrinsic sphincteric deficiency. Patient perception and satisfaction remain closely associated with presence or resolution of postoperative urge incontinence. However, prediction of postoperative urge incontinence remains a challenge and should be considered when counseling patients preoperatively.

Urodynamic findings in the tethered spinal cord syndrome: does surgical release improve bladder function?

PURPOSE: We retrospectively reviewed 39 patients with a tethered spinal cord to evaluate whether surgical release positively influenced urological symptoms or urodynamic findings. MATERIALS AND METHODS: The patients were divided into 2 groups: group 1-11 with occult spinal dysraphism and group 2-28 with secondary spinal cord tethering after previous closure of a myelomeningocele or resection of a lipomyelomeningocele. Diagnosis was confirmed in all cases by magnetic resonance imaging or spinal ultrasound. A comprehensive urodynamic evaluation was done immediately preoperatively and 2 to 21 months (mean 7) postoperatively. RESULTS: In group 1 the most common preoperative urodynamic finding was hyperreflexia, which improved or resolved after untethering in 62.5% of the patients. Four adults also reported improved bladder sensation or decreased urgency. In group 2 the most common urodynamic finding was impaired compliance, followed closely by detrusor hyperreflexia. Urodynamic patterns of detrusor hyperreflexia or compliance improved in only 30% of the patients, while 48% had worsened patterns. Only 14% of group 2 had improved symptoms of urinary control but 28% had improved lower extremity function. CONCLUSIONS: Urological symptoms and urodynamic patterns may be improved by early surgical intervention in patients with occult spinal dysraphism. However, untethering did not consistently benefit patients with secondary spinal cord tethering.

Post-prostatectomy incontinence and the artificial urinary sphincter: a long-term study of patient satisfaction and criteria for success.

PURPOSE: We investigated patient satisfaction with the artificial urinary sphincter and established criteria for a successful outcome by inquiring about patient perceived satisfaction, continence achieved and comparison with the surgeon office records. MATERIALS AND METHODS: During 9 years 65 patients with post-prostatectomy incontinence underwent placement of the AMS800 artificial urinary sphincter. Review of charts and a telephone questionnaire were conducted to determine patient perceived satisfaction. RESULTS: A total of 50 patients participated in the survey. Median followup was 23.4 months. Preoperative incontinence was severe. Of the patients 90% reported continuous leakage, and 70% wore an average of 6 diapers and 24% wore an average of 7.4 pads daily. The long-term complete continence rate was 20%. Of the patients with wetness 55% had leakage of a few drops daily and 22% had leakage of less than a teaspoon. Of all patients 50% had leakage daily, 24% had leakage 1 or more times a week and wore an average of 1.5 pads per day, and 6% reported changing clothes due to wetness. A total of 90% of the patients reported satisfaction with the artificial urinary sphincter and 96% stated that they would recommend or had recommended the artificial urinary sphincter to a friend. In retrospect, 92% of the patients would have the artificial urinary sphincter placed again, 90% of those undergoing revision reported no change in satisfaction and 14% reported improved sexual activity. CONCLUSIONS: Patient satisfaction with the artificial urinary sphincter for post-prostatectomy incontinence is uniformly high. Although postoperative continence was not 100%, relative improvement in continence was the most significant factor affecting patient perceived outcome. Using these parameters criteria for a successful outcome can be established, and patient concerns regarding the artificial urinary sphincter can be dispelled.

Mucinous adenocarcinoma in defunctionalized bladders.

Primary adenocarcinoma of the bladder accounts for less than 2% of all bladder cancers. There is no report of such a case in a defunctionalized bladder. All reported cases of carcinoma in defunctionalized bladders were either squamous cell, signet ring cell, or transitional cell carcinoma, detected within an average of 5 years after urinary diversion, and all have been associated with chronic inflammation of the bladder. We report on 2 cases of adenocarcinoma that developed in defunctionalized bladders 30 and 8 years after ileal loop diversion for prune belly syndrome and neurogenic bladder, respectively.

Radical retropubic prostatectomy for localized carcinoma of the prostate in a large metropolitan hospital: changing trends over a 10-year period (1984-1994). Dallas Outcomes Research Group for Urological Disorders.

OBJECTIVES: To analyze changing trends in the surgical treatment for localized carcinoma of the prostate in a large metropolitan community hospital over a 10-year period from 1984 to 1994. METHODS: The records of all 428 patients who underwent radical prostatectomy for localized carcinoma of the prostate from January 1, 1984, to January 1, 1994, at a large metropolitan community hospital (Baylor University Medical Center, Dallas, Tex) were retrieved and data abstracted in a predefined computerized database by a urology resident who was not part of the patient's surgical team. The abstracted data included attending surgeon, date of surgery, patient's age, clinical stage at presentation and pathologic stage, prostate-specific antigen (PSA), perioperative events, such as duration of surgery, blood loss, transfusion, duration of hospital stay, comorbidities according to the Charlson comorbidity index, and others. The data were analyzed in regard to changes over the 10-year period and stratified by a variety of parameters. RESULTS: The number of radical prostatectomies performed increased by fourfold from 1984 to 1993. The distribution of clinical stage and the incidence of pathologic upstaging noted in the 428 cases were similar to other series reported in the literature. The average age of patients decreased from 67 to 63 years over the 10 years (average calculated in increments of 15 cases in ascending order). Similarly, over time the average duration of surgery, average blood loss, average use of transfusion, and the average duration of hospital stay decreased. When the cases were grouped by individual attending surgeon, whose numerical surgical experience during that time period ranged from 1 to 76 cases, no correlation was noted between the numerical experience and these outcomes. CONCLUSIONS: As opposed to the national Medicare experience recently reported by the Prostate Patients Outcome Research Team, the increase in the number of cases performed was mostly due to patients under the age of 70 years, considered reasonable candidates for radical prostatectomy. Independent of numerical experience of individual attending surgeons, duration of surgery, blood loss, transfusion rates, and duration of hospital stay decreased during this period. This might indicate a learning effect due to continuing education, exchange of ideas, published technical improvements in the surgical procedure, and other factors, ultimately benefiting the patient by improving outcomes.

Anastomotic suture granuloma following radical retropubic prostatectomy.

We report 2 cases of symptomatic suture granuloma formation after erosion of the silk suture (used to ligate the dorsal venous complex) into the urethrovesical anastomosis. Irritative or obstructive voiding complaints, sterile pyuria or hematuria found after radical retropubic prostatectomy mandates urological evaluation, including cystoscopy to rule out anastomotic suture granuloma formation. Although erosion appears to be a rare occurrence, we recommend use of absorbable suture to control the dorsal venous complex and avoid this possible complication.