Surgery is inadvisable: massive varicocele due to portal hypertension.

The pathophysiology of idiopathic varicoceles as a dilatation of the pampiniform venous plexus has been traced to anatomical and embryological development, but is still unclear. Right or non-decompressible lesions are worrisome for retroperitoneal pathology, such as renal cell carcinoma, hydronephrosis, abdominal neoplasm or fibrosis. As a very rare finding we describe a patient who presented with an exorbitant left sided varicocele due to portal hypertension. We were well advised to avoid surgery.

Botulinum-A toxin detrusor and sphincter injection in treatment of overactive bladder syndrome: objective outcome and patient satisfaction.

OBJECTIVE: We investigated the effect of botulinum-a toxin injections into the detrusor and external sphincter muscle in patients with overactive bladder (OAB) symptoms. METHODS: We included 44 patients - 41 women and three men with a mean age of 66.1 years - who were suffering from OAB symptoms that were refractory to anticholinergic treatment. We injected 200-300 U of BTX-A (Botox) into the detrusor muscle; 22 patients also received external sphincter injections. For outcome analysis, we used a bladder diary, a urodynamic examination, and a questionnaire that consisted of 27 validated questions. RESULTS: Changes in the bladder diary 4 weeks and 3, 6, and 9 months after BTX-A injection were as follows: Micturition frequency was reduced by 12%, 16%, 13% and 9%, respectively. Average pad use decreased from 4.2 pads per day to at most 2.4 pads per day after 6 months. Urodynamic changes were most distinct after 4 weeks: the volume when the first uninhibited detrusor contraction occurred increased from 149+/-18.2 mL to 263 +/- 24.2 mL, and maximum cystometric bladder capacity increased from 228 +/- 19.2 mL to 305 +/- 19.0 mL. Subjectively, 86% of the patients would choose this procedure for their bladder condition again. Residua 4 weeks after additional injection into the sphincter muscle were distinctly smaller than in the "only detrusor" group. CONCLUSIONS: BTX-A detrusor and sphincter injection is very effective in treating OAB symptoms. For patients who might be expected to have residual urine after injection only into the detrusor, additional injection of low doses of BTX-A into the external sphincter muscle could be one option to reduce that risk.

Botulinum-A toxin for treatment of overactive bladder without detrusor overactivity: urodynamic outcome and patient satisfaction.

OBJECTIVES: To investigate the effect of botulinum toxin type A bladder injections in the treatment of overactive bladder syndrome in the absence of detrusor overactivity. METHODS: The subjects were 7 women (average age 61.1 years, range 51 to 79) who presented with overactive bladder symptoms. Their disorder had been refractory to several classic treatment options. Urodynamic examination excluded detrusor overactivity. A total of 300 U BTX-A (Botox) was injected, of which 50 to 75 U was injected as quadrant injections into the external sphincter muscle to avoid the postoperative need for catheterization in the case of high postvoid residual urine volume. For follow-up, complete urodynamic studies were performed, and a bladder diary and validated incontinence questionnaires were given to patients at all visits at 1, 3, and 6 months. RESULTS: The bladder diaries indicated a clear reduction in daytime frequency and nocturia and a reduction in pad use. The maximal voiding volume increased significantly. The urodynamic examinations showed a significant increase in volume when the first and the strong desire to void were expressed. The maximal bladder capacity increased by 20% in 3 months. In the questionnaires, 5 of the 7 patients reported better urine control after therapy, and 6 would have chosen this therapy again for their condition. The overall satisfaction score (on a scale of 0 to 10) averaged 6.8. No side effects, such as urine retention, occurred. CONCLUSIONS: Botulinum-A toxin injection has positive effects in treating overactive bladder symptoms without detrusor overactivity. The effects were seen not only in urodynamic measures but also in patient satisfaction.

Orandi one-stage urethroplasty using the subcutaneous pedicle graft modification of Raatzsch--long-term results.

OBJECTIVE: To present long-term results obtained with the Orandi one-stage urethroplasty using a modified technique as described by Raatzsch. MATERIAL AND METHODS: Between 1980 and 1993, Raatzsch urethroplasty was used in our clinic in 202 male patients (average age 50.9 years), 53% of whom had undergone other procedures before, mainly internal urethrotomy. The mean follow-up period was 46.2 months (range 2-156 months). RESULTS: Good or improved results with no need for further surgical intervention were achieved in 128 patients (63.4%); a total of 117 procedures had to be performed in the other 74 patients in order to achieve a satisfactory outcome. The success rate was highest for penile strictures (71.8%). Complications occurred in 24.3% of cases. CONCLUSIONS: The Raatzsch modification of Orandi urethroplasty is a simple procedure that yields moderate results on long-term follow-up. Surgeons who operate regularly for urethral stricture should be aware of its long-term results, especially in the treatment of penile strictures.