Carol J. Bennett

Lower urinary tract reconstruction following cystectomy; experience and results in 126 patients using the Kock ileal reservoir with bilateral ureteroileal urethrostomy

Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patient acceptance with few late complications or need for reoperation.

Lower Urinary Tract Reconstruction Following Cystectomy In Women Using The Kock Ileal Reservoir With Bilateral Ureteroileal Urethrostomy: Initial Clinical Experience

Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.

Predictors of Success in Electroejaculation of Spinal Cord Injured Men

Rectal probe electroejaculation was attempted in 48 spinal cord injury men and greater than 10 million sperm were obtained in 71%. Patient age and interval since injury had no effect on outcome. The best performance was seen in thoracic paraplegics and in those using intermittent catheterization for bladder management. Indwelling urethral catheters and high pressure reflex voiding had a negative impact on electroejaculation results.

Comparison of Bladder Management Complication Outcomes in Female Spinal Cord Injury Patients

A total of 70 female spinal cord injury patients was retrospectively analyzed for outcomes of long-term bladder management. Three groups were defined: 1) 23 patients on intermittent catheterization, 2) 25 treated by reflex voiding and incontinence padding, and 3) 22 with an indwelling catheter. Mean years of using the specific bladder management technique were 8.5 +/- 4.7, 15.8 +/- 7.3 and 16.7 +/- 9.0 for the 3 groups, respectively. All patients were evaluated for long-term complications. There were 4 major complications (17%) in the intermittent catheterization group, 10 (40%) in the padding group and 58 (greater than 200%) in the indwelling catheter group. The aggregate difference in complication rates among the 3 group was highly significant (p < 0.00001). Of comparable long-term patients (11 to 23 years) there were no major complications among 6 on intermittent catheterization, 8 among 14 who use padding and 21 among 9 with an indwelling catheter. The differences among the groups remained significant (p < 0.00001). Additional analyses showed highly significant differences between the catheter group and the other 2 groups (intermittent catheterization p = 0.0009 and padding p = 0.0005), and a difference that approached significance between the intermittent catheterization and padding groups (p = 0.085). The results strongly support intermittent catheterization as the optimal management of female patients following spinal cord injury given that other factors, in particular independent hand function or the need for appropriate assistance, are considered.

Electroejaculation following retroperitoneal lymphadenectomy.

Transrectal electroejaculation was performed in 24 men who were anejaculatory from retroperitoneal lymphadenectomy. Of the men 23 had undergone retroperitoneal lymphadenectomy because of testis cancer. Seminal emission was achieved in all patients. In 21 patients greater than 10 x 10(6) progressively motile sperm with normal morphology were obtained. The average sperm count and motilities obtained were 289 x 10(6) and 18%, respectively, for the antegrade fractions, and 2,051 x 10(6) and 13%, respectively, for the retrograde fractions. Of the 3 azoospermic failures 2 had chemotherapy-induced testicular damage and 1 had carcinoma in situ of the remaining testis. A total of 19 couples underwent artificial insemination with electroejaculated sperm. There were 7 pregnancies achieved in 74 insemination cycles (36.8% of the couples conceived for a 9% cycle fecundity). Routine semen parameters could not predict which couples would be successful in achieving pregnancy. There were 2 first trimester spontaneous abortions. Five healthy children have been born. Electroejaculation is an excellent treatment for anejaculation that persists following retroperitoneal lymph node dissection.

SPHINCTERIC STENT VERSUS EXTERNAL SPHINCTEROTOMY IN SPINAL CORD INJURED MEN: PROSPECTIVE RANDOMIZED MULTICENTER TRIAL

PURPOSE In a prospective randomized multicenter trial we compared the treatment results of conventional external sphincterotomy with those of UroLume sphincteric stent prosthesis placement in men with spinal cord injury and external detrusor-sphincter dyssynergia. MATERIALS AND METHODS We randomized 57 men with spinal cord injury in whom urodynamics verified external detrusor-sphincter dyssynergia into 2 groups to undergo either sphincter defeating procedure. We compared the primary urodynamic parameter of maximum detrusor pressure, and secondary urodynamic parameters of bladder capacity and post-void residual urine volume in men who underwent sphincterotomy or sphincteric stent placement. Parameters were measured preoperatively, and 3, 6, 12 and 24 months postoperatively. Patients completed questionnaires regarding voiding sensation and quality of life issues at each followup visit. RESULTS Demographic data of the 26 patients treated with sphincterotomy and the 31 treated with sphincteric stent placement were statistically similar. Preoperatively mean maximum detrusor pressure plus or minus standard deviation in sphincterotomy and stent cases was 98.3 +/- 27.6 and 95.7 +/- 27.7 cm. water, respectively (p = 0.73). At 12 months mean maximum detrusor pressure decreased to 48.9 +/- 16.4 and 52.6 +/- 31.6 cm. water in the sphincterotomy and stent groups, respectively (p = 0). Preoperatively mean bladder capacity in sphincterotomy and stent cases was 245 +/- 158 and 251 +/- 145 ml., respectively (p = 0.87). Bladder capacity did not change significantly in either treatment group throughout followup. Preoperatively mean post-void residual urine volume in the sphincterotomy and stent groups was 212 +/- 163 and 168 +/- 114 ml., respectively (p = 0.33). Residual urine volume decreased in each group at some but not all followup evaluations. The duration of hospitalization was greater for sphincterotomy than stenting (p = 0.036). Six stents required explantation. CONCLUSIONS The UroLume stent is as effective as conventional external sphincterotomy for treating external detrusor-sphincter dyssynergia. However, sphincteric stent placement is advantageous because it involves shorter hospitalization and is potentially reversible.

Options in Replacement Cystoplasty Following Radical Cystectomy: High Hopes or Successful Reality

Currently, the classical, time-honored ileal conduit as well as the stoma1 continent urinary diversions have given way to the increasingly frequent use of replacement cystoplasty. In 1852 Simon performed the first continent urinary diversion in a form of ureterorectal anastomosis on a paitent with ectopia vesicae’ and in 1913 Lemoine reported the first true clinical use of a rectal bladder.2 This and most of the following attempts would be tempered by a high surgical mortality rate. In 1951 Couvelaire reported the first clinical use of bladder substitution, which was followed by only sporadic reports on this method.3 Since Kock et a1 in 1982 reported on their pioneering experience with the use of an ileal segment for the construction of a continent reservoir: we have witnessed an explosion of interest in continent urinary reconstructions via the cutaneous and urethrally anastomosed forms. The number of variants currently average more than 40 worldwide.4-7 Bladder replacement by a variety of small and large bowel segments has become a standard method of reestablishing voiding per urethra. Typical causes for replacement cystoplasty, defined as total cystectomy followed by reconstruction, are bladder carcinoma (the leading cause in adults), surgically unreparable bladder exstrophy, undiversion and a diseased vesicourethral unit requiring total cystectomy.8 TO date, radical cystectomy remains the most effective method of treatment for invasive bladder carcinoma. Despite all of the advances in chemotherapy and radiotherapy, these modalities have still not been demonstrated to be equivalent to surgery in terms of survival, local or regional control, or quality of life. Major refinements in anesthetic procedures, the advent of the modern antibiotic era, and recent advances in surgical, urodynamic and metabolic knowledge have significantly decreased mortality and morbidity rates associated with cystectomy and urinary reconstruction. h y patient undergoing radical cystectomy will be confronted with the option of selecting 1 of 3 types of definitive urinary diversion: 1) the ileal or colon conduit, 2) a cutaneous continent reservoir and 3) a neobladder for orthotopic voidingg Option 3, hitherto reserved exclusively for men, has recently been performed successfully following radical cystectomy in the female patient.10-15 An intensive quest is underway to develop an orthotopic continent reservoir, resembling the natural bladder as close as possible, that is technically acceptable to surgeons and the most socially acceptable to patients. At the same time, it is important that any such bladder replacement procedure protects the upper urinary tract. This event is even more rewarding since followup is hoped to match normal life expectancy. Some disillusionment with long-term results of the ileal conduit, particularly in children, added to economic factors, particularly in Some third world countries where the cost of ostomy appliances is prohibitive, have also been responsible for this swing. We review what we believe to be only some of the most commonly used neobladders (bladder replacement in situ with the native urethra) to date, covering the most salient technical features. Basic physical and mathematical principles related to morphology and functional behavior of neobladders will be followed by a brief discussion of the rationale for recommending this type of procedure to post-radical cystectomy patients, probably regardless of gender. However, it should always be kept in mind that “urinary continence must not be achieved to the detriment of renal function” as stated by Bricker more than 4 decades ago.16 This statement still remains valid to date.

Adverse prognostic features of collagen injection therapy for urinary incontinence following radical retropubic prostatectomy

PURPOSE We identified and characterized predictive factors associated with an unfavorable outcome of collagen injection therapy in post-radical prostatectomy incontinence. MATERIALS AND METHODS A total of 46 patients, 49 to 85 years old (mean age 67) and incontinent after radical retropubic prostatectomy, underwent a mean of 2.8 transurethral injections of collagen (mean cumulative volume injected 31 ml.). Preoperatively, all patients underwent fluoroscopic multichannel video urodynamics including determination of Valsalvas leak point pressure. Stress urinary incontinence was subjectively graded as 1 (0 to 1 pad per day), 2 (2 to 3 pads per day) and 3 (greater than 3 pads per day). Patient age, duration and severity of pretreatment incontinence, presence of detrusor instability and anastomotic strictures, number of injections, total volume of collagen delivered and the impact of a nerve sparing procedure plus adjuvant radiation therapy were assessed and correlated with treatment outcome. RESULTS Of the patients 11 (24%) became completely dry (9 after 3 or fewer treatments), 21 (41%) improved (17 after 3 or fewer treatments) and 14 (30%) showed no benefit (after more than 3 treatments). Of the 14 patients in whom treatment failed 6 had undergone adjuvant radiation treatment, pretreatment urinary incontinence was grade 3 in all, and concomitant detrusor instability was present in 11 (79%). All patients had received more than 3 treatments (mean total volume injected 37 ml.). CONCLUSIONS Notwithstanding the need for multiple treatments, the prospect for cure by collagen injection of the post-radical prostatectomy incontinent patient is significantly affected by the severity of pretreatment incontinence, concomitant detrusor overactivity and exposure to radiation therapy. Age, duration of incontinence, presence of mild to moderate anastomotic strictures and a nerve sparing technique did not seem to influence treatment outcome.

The 28K protein in urinary bladder, squamous metaplasia and urine is triosephosphate isomerase

OBJECTIVES The objective of this study was to establish the identity of a protein found in high concentrations in squamous metaplasia of the bladder. DESIGN AND METHODS The protein was isolated and subjected to a series of physical, chemical, and catalytic studies. RESULTS In the normal urothelium the protein was confined to a juxtanuclear pattern on the luminal side of the umbrella cells; in squamous metaplasia and squamous cell carcinoma the protein was increased and exhibited a more diffuse intracellular distribution. The protein was found to be identical to triosephosphate isomerase (EC 5.3.1.1; TPI) with respect to its immunological properties, native and subunit molecular weights, electrophoretic mobility, catalytic activity, and amino acid sequence. CONCLUSIONS While the basis for the altered distribution of TPI remains to be established, the increased amounts of the protein in urine or bladder tissue may be indicative of squamous metaplasia, squamous cell carcinoma, or other bladder injuries.

Lower urinary tract reconstruction in the female using the kock ileal reservoir with bilateral ureteroileal urethrostomy: Update of continence results and fluorourodynamic findings

OBJECTIVES To update continence results and present fluorourodynamic data in 17 female patients undergoing orthotopic lower urinary tract reconstruction with the Kock ileal urethrostomy following cystectomy. METHODS Continence results, voiding pattern, and overall patient satisfaction were evaluated by means of patient survey. Fluorourodynamic data and abdominal leak point pressures were obtained in 6 patients. RESULTS Complete daytime urinary continence was reported in 93% of patients, whereas complete nighttime continence was reported by 87% of patients. Fluorourodynamic studies demonstrated excellent neobladder capacity with low reservoir pressure in all cases. Abdominal leak point pressure measurements confirmed normal urethral sphincter function. CONCLUSIONS Excellent results with respect to urinary continence, voiding pattern, patient satisfaction, and reservoir function can be expected in women undergoing orthotopic lower urinary tract reconstruction.