Bernard Lytton

Pubovaginal Sling Procedure for Stress Incontinence

Urinary stress incontinence associated with poor urethral sphincter function and indicated by a urethral pressure of less than 10 cm. water was treated in 52 cases with a pubovaginal autogenous fascial sling. No urethral sphincter function could be measured in 7 patients. Of these 52 patients 42 had undergone a previous operation for stress incontinence. The uninhibited detrusor dysfunction that accompanied the stress incontinence in 29 cases ceased after operation in 20 but persisted in 9. Postoperative urethral pressure measurements indicated that while the sling increased urethral pressure it did not cause an obstruction during voiding, since there was a measurable decrease in urethral pressure during a detrusor contraction. Urodynamic determination were useful in patient selection, in the adjustment of sling tension at operation and in the assessment of reasons for failure. A satisfactory result with good urinary control was obtained in 50 cases and the procedure was a failure in 2.

Treatment of Motor and Sensory Detrusor Instability by Electrical Stimulation

A new application of electrical stimulation to inhibit detrusor activity has been used in 15 patients with a variety of neural lesions. The results were astonishingly good and the device was well tolerated. In patients treated successfully for detrusor instability an absence of urgency occurred as a by-product of electrical stimulation. Therefore, stimulation was used to treat uncomfortable bladder urgency without detrusor instability and was successful in the majority of patients.

The Value of Urodynamic Testing in Stress Urinary Incontinence

Preoperative urodynamic testing for the identification of specific types of urinary incontinence was found useful to select an appropriate operative procedure. Failure of the operation to relieve stress incontinence was unusual in 346 patients followed for a minimum of 2 years. Of the total group of patients with stress incontinence 27 per cent also had detrusor instability identified urodynamically preoperatively. However, identification of the syndrome is of limited prognostic significance since the majority of these patients had no difficulty with the syndrome postoperatively and some other patients appeared to have the syndrome only postoperatively.

Early Experience with Direct Vision Electrohydraulic Lithotripsy of Ureteral Calculi

Rigid ureteroscopy is now an established technique for the management of ureteral stones. Manipulation of calculi can be done under direct vision using flexible forceps or stone baskets with increased safety and efficacy. We also have used a 5F electrohydraulic lithotripsy electrode to disintegrate stones that were too large to be removed by manipulation. Between October 1982 and January 1984, 36 ureteroscopies were performed for the removal of ureteral stones. In 26 cases (72 per cent) the stone was removed successfully. Electrohydraulic lithotripsy was used successfully to remove the stone in 9 cases (24 per cent) and there were no immediate complications. Followup with excretory urography in 7 of these patients 2 to 18 months after lithotripsy failed to reveal any evidence of long-term complications. We conclude that electrohydraulic lithotripsy under direct vision can be done safely if certain guidelines are adhered to strictly.

The Role of Vertebral Veins in the Dissemination of Prostatic Carcinoma

The concept that the vertebral system of veins acts as a direct conduit in the spread of prostatic carcinoma to the skeletal system is based on the poorly documented observation that this tumor metastasizes preferentially to the pelvis, lumbar spine and sacrum. We analyzed 99mtechnetium bone scans in patients with skeletal metastases from assorted primary tumors and found that the distribution of metastases was virtually identical in patients with prostatic and nonprostatic tumors. Of the patients with prostatic carcinoma 25 per cent had bone scan lesions exclusively outside the region of the sacrum, pelvis and lumbar spine. The distribution of skeletal metastases from prostatic carcinoma does not support the concept that the vertebral veins have a substantial role in the dissemination of this tumor.

Complications of Ureteral Endoscopy

Use of the rigid ureterorenoscope has become widely accepted for the diagnosis of ureteral lesions, and for the removal and disintegration of ureteral calculi. Few complications have been reported. During the last 3 years 128 ureteroscopic procedures were performed for a variety of indications (98 for stone disease). There were 26 complications: 22 minor with no morbidity and 4 major that required surgical correction. Minor complications consisted of asymptomatic ureteral perforations in 6 patients, perforations with urinary extravasation, pain, ileus or fever in 4, migration of the stone into the kidney in 10 and migration of the stone outside the ureter with the calculus left in situ in 2. Major complications included ureteral perforation during basket extraction of an upper ureteral stone, urinoma following perforation and requiring drainage, stenosis of the intramural ureter that was corrected by marsupialization and aseptic necrosis of the ureter that was treated by ileal replacement.

Treatment of Solitary and Bilateral Renal Carcinomas

Recent experience with 7 patients, as well as a review of the literature, indicates that partial nephrectomy provides satisfactory treatment of solitary and bilateral renal adenocarcinomas. Patient survival seems to be dependent on the adequacy of tumor resection and not on the fate of the contralateral kidney. Total nephrectomy, dialysis and subsequent transplantation are viable alternatives when it is technically not possible to preserve adequate renal parenchyma.

Urologic Complications of Inflammatory Bowel Disease

Urologic complications occurred in 54 of 233 patients with inflammatory bowel disease followed during a 15-year period. Urinary calculi, enterovesical fistulas and ureteral obstruction were the most common problems. Urinary tract complications may arise many years after primary bowel disease has been diagnosed. Symptoms frequently may be absent or obscured by those of the gastrointestinal disorder. We recommend that urologic evaluation be included periodically in the long-term management of patients with inflammatory bowel disease.

Intraoperative Localization of Renal Calculi During Nephrolithotomy by Ultrasound Scanning

An ultrasound B-scan probe has proved to be useful in the intraoperative localization of renal calculi. The probe is small, readily available and produces an anatomical cross-sectional image of the kidney. The use of a 10 MHz. frequency probe enables 2 to 3 mm. stones to be detected readily. Calibration of the screen and the use of a fine needle inserted into the kidney under ultrasound control provide for precise 3-dimensional localization of the stone to facilitate its removal. The method has been successful in accomplishing the complete removal of small stones or residual fragments in 7 of 11 patients in whom it has been used. The method requires some experience in the use of the probe and in the interpretation of the ultrasound image.

Antibiotic Treatment of Renal Carbuncle

Renal carbuncles in seven young males were successfully treated with long-term administration of penicillinase-resistant antibiotics. Selective renal arteriography provided an accurate means of diagnosis and permitted a trial of medical therapy. All patients experienced a prompt and sustained clincial remission; surigical exploration was thus obviated in all but one instance, in which post-treatment radiographic changes persisted.