Anthony R. Mundy

THE LONG-TERM OUTCOME OF ARTIFICIAL URINARY SPHINCTERS

PURPOSE We reviewed the outcome of artificial urinary sphincters inserted more than 10 years ago. MATERIALS AND METHODS We analyzed the records of 100 patients and mailed a questionnaire to those without recent followup. RESULTS Overall 84 patients were continent, including 36 with the original artificial urinary sphincter in place who were dry at a median followup of 11 years and 27 in whom the device was successfully replaced due to mechanical failure who were previously continent for a median of 7 years. In 21 patients it was removed due to infection or erosion and reimplantation was successful 3 to 6 months later or they remained dry without another artificial urinary sphincter. Of the male patients with a bulbar and bladder neck sphincter 92% and 84%, respectively, were continent at 10 years as well as 73% of the females. Device survival was 66% at 10 years. Overall 37% of the prostheses were removed due to infection or erosion in the 10-year period with the highest risk in females (56%) and lowest in males with a bulbar sphincter (23%). CONCLUSIONS The artificial urinary sphincter is effective long-term treatment for incontinence in male patients. In female patients the risk of erosion is high, although overall long-term continence is satisfactory.

Augmentation cystoplasty: AUGMENTATION CYSTOPLASTY

Many patients with small-capacity, high-pressure, poorly compliant or unstable bladders will be managed successfully with pharmacological or other conservative measures. A small but signi®cant minority of these patients will require surgical intervention, the therapeutic goals of which are to provide urinary storage whilst preserving renal function, continence, resistance to infection and convenient voluntary and complete emptying.

A QUANTITATIVE STUDY OF ATROPINE-RESISTANT CONTRACTILE RESPONSES IN HUMAN DETRUSOR SMOOTH MUSCLE, FROM STABLE, UNSTABLE AND OBSTRUCTED BLADDERS

PURPOSE The objective of the study was to quantify in vitro the magnitude of atropine-resistant contractions using human detrusor samples and to determine the cellular processes underlying these contractions. MATERIALS AND METHODS Isometric contractile responses were measured in isolated strips of human detrusor muscle obtained from patients with i) stable, ii) unstable or iii) obstructed bladders. Preparations were electrically stimulated or exposed to carbachol and ATP in the superfusate. RESULTS Force-frequency curves were shifted to the right in samples from unstable and obstructed bladders. These same tissue groups also showed significant atropine-resistant contractions which were abolished by the neurotoxin TTX, or the non-hydrolysable ATP analog, alpha,beta-methylene ATP, suggesting that these contractions were mediated by neurally released ATP. Sub-division of the patient group with unstable bladders demonstrated that those with neuropathic instability did not show atropine-resistance, whereas those with idiopathic instability or secondary instability after obstruction did show atropine-resistant contractions. The potency of carbachol in generating a contracture was significantly greater than ATP (mean EC50 0.65 microM and 151 microM respectively) however, for each agonist there was no difference in potency between the three patient groups. Direct muscle excitability was similar in all three patient groups. CONCLUSIONS It is concluded that purinergic, atropine-resistant contractions are present in some types of dysfunctional bladder, and these are not caused by a differential sensitivity of the muscle to ATP and cholinergic agonists.

SUBSTITUTION URETHROPLASTY WITH BUCCAL MUCOSAL-FREE GRAFTS

PURPOSE Buccal mucosal grafts and the Barbagli technique are recent developments in the treatment of urethral strictures. MATERIALS AND METHODS We reviewed the results of and experience with urethroplasty using buccal mucosal graft in 128 patients. RESULTS The re-stricture rate was 11% for patch grafts and 45% for tube grafts. There were no other complications. CONCLUSIONS Buccal mucosal graft is at least as good as any other material for substitution urethroplasty with fewer complications. The 2-stage is more reliable than the stage 1 approach for circumferential reconstruction of the urethra.

Photodynamic Therapy for Prostate Cancer Recurrence After Radiotherapy: A Phase I Study

PURPOSE Photodynamic therapy, using a photosensitizing drug activated by red light, can destroy localized areas of cancer with safe healing and without the cumulative toxicity associated with ionizing radiation. We used photodynamic therapy in a phase I-II study to treat patients with locally recurrent prostate cancer after radiotherapy. MATERIALS AND METHODS Patients with an increasing prostate specific antigen (PSA) and biopsy proven local recurrence after radiotherapy were offered photodynamic therapy. Three days after intravenous administration of the photosensitizer meso-tetrahydroxyphenyl chlorin, light was applied using optical fibers inserted percutaneously through perineal needles positioned in the prostate with imaging guidance. Patients were followed with PSA measurements, prostate biopsies, computerized tomography or magnetic resonance imaging and questionnaires on urinary and sexual function. RESULTS Photodynamic therapy was given to 14 men using high light doses in 13. Treatment was well tolerated. PSA decreased in 9 patients (to undetectable levels in 2) and 5 had no viable tumor on posttreatment biopsies. After photodynamic therapy, contrast enhanced computerized tomography or magnetic resonance imaging showed necrosis involving up to 91% of the prostate cross section. In 4 men stress incontinence developed (troublesome in 2 and mild in 2) which is slowly improving. Sexual potency was impaired in 4 of the 7 men able to have intercourse before photodynamic therapy, which did not improve. There were no rectal complications directly related to photodynamic therapy, but in 1 patient a urethrorectal fistula developed following an ill-advised rectal biopsy 1 month after therapy. CONCLUSIONS Photodynamic therapy is a new option that could be suitable for organ confined prostate cancer recurrence after radiotherapy. With more precise light dosimetry, it may be possible to destroy essentially all glandular tissue within the prostate with few complications. These results suggest that photodynamic therapy merits further investigation.

Consensus statement on urethral trauma.

In this continuation of the section on genitourinary trauma, the authors describe the consensus on urethral injury. This is an in‐depth statement, describing all aspects of the condition, from anatomy to general recommendations.

The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra.

Objective To compare the surgical outcome using buccal mucosal free grafts in the Barbagli procedure (dorsal stricturotomy and patch technique) with the traditional ventral approach, for long bulbar urethral strictures.

Urethral strictures: URETHRAL STRICTURES

What’s known on the subject? and What does the study add?

Neuromodulation by Implant for Treating Lower Urinary Tract Symptoms and Dysfunction

Objective: Patients with irritative micturition complaints, pelvic pain, involuntary urine loss or urinary retention are sometimes difficult to treat. The advent of direct sacral nerve stimulation offers a therapeutic alternative if conservative measures fail and surgery is considered. This paper reviews therapeutic neuromodulation by implant for treating lower urinary tract symptoms and dysfunction. Methods: The international literature is reviewed on topics such as the physiological basis of neuromodulation, techniques of acute testing and chronic implantation, and clinical results. Future developments and ways for possible improvement are discussed. Results: The mode of action of neuromodulation is probably through restoring the correct balance between excitatory and inhibitory impulses from and to the pelvic organs at a sacral and supra-sacral level. Depending on the predefined success criteria, average success rates of definitive implants vary from 50 to 70%. From the data it seems that patients with urge incontinence and urinary retention are the best candidates for neuromodulation. In the literature the lack of standardisation of selection criteria, stimulation parameters and definitions of success is striking. Conclusions: Neuromodulation by implant is a useful therapeutic alternative. It should at least be considered in patients with therapy-resistant urge incontinence and urinary retention before proceeding to surgery. Issues such as underlying physiologgy, methodological standardisation, technical improvements, and patient selection must be addressed in future research.

Defining a Patient-Reported Outcome Measure for Urethral Stricture Surgery

BACKGROUND A systematic literature review did not identify a formally validated patient-reported outcome measure (PROM) for urethral stricture surgery. OBJECTIVE Devise a PROM for urethral stricture surgery and evaluate its psychometric properties in a pilot study to determine suitability for wider implementation. DESIGN, SETTING, AND PARTICIPANTS Constructs were identified from existing condition-specific and health-related quality of life (HRQoL) instruments. Men scheduled for urethroplasty were prospectively enrolled at five centres. INTERVENTION Participants self-completed the draft PROM before and 6 mo after surgery. MEASUREMENTS Question sets underwent psychometric assessment targeting criterion and content validity, test-retest reliability, internal consistency, acceptability, and responsiveness. RESULTS AND LIMITATIONS A total of 85 men completed the preoperative PROM, with 49 also completing the postoperative PROM at a median of 146 d; and 31 the preoperative PROM twice at a median interval of 22 d for test-retest analysis. Expert opinion and patient feedback supported content validity. Excellent correlation between voiding symptom scores and maximum flow rate (r = -0.75), supported by parallel improvements in EQ-5D visual analogue and time trade-off scores, established criterion validity. Test-retest intraclass correlation coefficients ranged from 0.83 to 0.91 for the total voiding score and 0.93 for the construct overall; Cronbachs α was 0.80, ranging from 0.76 to 0.80 with any one item deleted. Item-total correlations ranged from 0.44 to 0.63. These values surpassed our predefined thresholds for item inclusion. Significant improvements in condition-specific and HRQoL components following urethroplasty demonstrated responsiveness to change (p < 0.0001). Wider implementation and review of the PROM will be required to establish generalisability across different disease states and for more complex interventions. CONCLUSIONS This pilot study has defined a succinct, practical, and psychometrically robust PROM designed specifically to quantify changes in voiding symptoms and HRQoL following urethral stricture surgery.