Christophe E. Iselin

PUBOVAGINAL SLING USING CADAVERIC ALLOGRAFT FASCIA FOR THE TREATMENT OF INTRINSIC SPHINCTER DEFICIENCY

PURPOSEnPubovaginal sling is the definitive management of female stress urinary incontinence due to intrinsic sphincter deficiency. Customarily, autologous fascia has been used, although synthetic material has its proponents. Harvesting autologous fascia at surgery is associated with postoperative discomfort, and synthetic material has a history of infection and erosion. To assess whether allograft fascia is free from these drawbacks, we retrospectively compared the outcome of women undergoing pubovaginal sling using either autologous or cadaveric allograft fascia.nnnMATERIALS AND METHODSnWe reviewed our experience during the last 28 months with patients treated with the pubovaginal sling for intrinsic sphincter deficiency. All patients underwent preoperative video urodynamics. The outcome was assessed using the SEAPI scoring system. Special attention was devoted to local sling tolerance. Operative time and length of hospital stay were compared between patients with allograft and autograft pubovaginal sling.nnnRESULTSnA total of 92 women (mean age 60 years) underwent allograft (59) or autograft (33) pubovaginal sling. Preoperative parameters, such as percent of patients who had had previous incontinence surgery, mean leak point pressure and SEAPI incontinence score, were similar in both populations. Mean followup was 11.5 months (range 1 to 28) for the overall population. The SEAPI scoring system showed that patients were markedly improved, with no significant difference between the allograft and autograft groups. Allograft and autograft pubovaginal slings were equally well tolerated, and no infection or erosion was encountered. Mean operative time and hospital stay were significantly shorter when using allograft compared to autograft fascia.nnnCONCLUSIONSnThe success rates of allograft and autograft pubovaginal sling were equally high, and no complications related to the cadaveric origin of the allograft fascia were observed. Allograft pubovaginal sling was well tolerated, and its use significantly shortened operative time and hospital stay.

Radical perineal prostatectomy : oncological outcome during a 20-year period

PURPOSEnWe examined 4 postulates: 1) radical perineal prostatectomy provides a substantial disease control benefit in men with clinically confined prostate cancer, 2) postoperative prostate specific antigen (PSA) levels are an excellent surrogate end point for defining disease control, 3) the biology of primary malignancy defines the interval to death after recurrence and 4) the interval from intervention to death from recurrence is so long that current series of alternative curative therapies have insufficient duration of observation to permit a comparison with the results of surgery.nnnMATERIALS AND METHODSnA total of 1,242 men with a median age of 65.2 years who had stage cT1 to 2 N0M0 disease underwent radical perineal prostatectomy. The final pathology specimen was characterized in regard to disease extent, and Gleason grade and score. Patients were followed at 2 weeks, at 2 months and then at 6-month intervals for biochemical, physical and radiographic evidence of disease recurrence. Outcome was evaluated by determining time to biochemical failure (PSA 0.5 ng./ml. or greater) and cancer associated death.nnnRESULTSnMedian time to noncancer death was 19.3 years. Median cancer associated death end point was not reached by patients with organ and specimen confined disease, while it was 12.7 years for margin positive disease. At 5 years 8, 35 and 65% of the patients with organ confined, specimen confined and margin positive disease, respectively, had PSA failure. This served as an excellent surrogate end point, preceding cancer associated death by 5 to 12 years depending on the biological aggressiveness predicted by Gleason grade or score. Biologically aggressive organ confined disease that had been surgically removed was associated with a high percentage of disease-free survival.nnnCONCLUSIONSnOur study confirms our postulates. It also provides guidelines for comparing therapies among institutions and emphasizes that enthusiasm for new treatments may be based on insufficient followup. Patient selection may severely bias outcome independent of treatment when death is used as the end point. Our study establishes the value of PSA as a surrogate end point.

DORSAL ONLAY GRAFT URETHROPLASTY FOR REPAIR OF BULBAR URETHRAL STRICTURE

PURPOSEnWe report the early outcome of dorsal full-thickness penile skin grafts in the repair of bulbar urethral stricture.nnnMATERIALS AND METHODSnDuring 27 months 29 men with a mean age of 43 years (range 10 to 81) underwent dorsal onlay graft urethroplasty. Followup included retrograde urethrogram at 3 weeks, 3 months and 12 to 18 months, and thereafter when needed. Urinary flow was recorded as subjectively reported by the patients.nnnRESULTSnThe technique was used only for bulbar urethral strictures. A total of 23 patients (79%) had undergone previous direct vision urethrotomy and/or open surgery. Dorsal onlay graft urethroplasty was used alone in 12 patients (41%), and was performed with partial stricture excision and ventral strip anastomosis in 13 (45%). In another 4 patients (14%) the procedure was combined with an Orandi flap because the stricture extended significantly into the penile urethra. Penile skin grafts were used in 27 patients (93%), whereas buccal mucosa was harvested in 2. Mean graft length was 6 cm. (range 3 to 9), and width ranged between 1.5 and 3 cm. Outcome was favorable in 28 patients (97%) for a median followup of 19 months (range 10 to 37). One patient had symptomatic proximal stricture recurrence and 3 had radiographic evidence of caliber decrease of the repair but with no impact on urinary flow.nnnCONCLUSIONSnDorsal onlay graft urethroplasty is a versatile procedure which may be combined with stricture excision and ventral strip anastomosis or an Orandi flap. Conceptually the technique offers the advantages of spread fixation of the graft on a fixed well vascularized surface, which may improve graft neovascularization, reduce graft shrinkage and avoid sacculation. Although the early outcome is promising, dorsal onlay graft urethroplasty has yet to stand the test of time.

THE SIGNIFICANCE OF THE OPEN BLADDER NECK ASSOCIATED WITH PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS

PURPOSEnAs a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997.nnnRESULTSnOf the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage.nnnCONCLUSIONSnOpen bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

Surgical Control of Clinically Localized Prostate Carcinoma Is Equivalent in African-American and White Males

Few studies have compared the outcome of radical prostatectomy between African‐American males (AAM) and white males, and the results of the few studies that have are conflicting. Therefore, the authors examined the impact of radical surgery on localized prostate carcinoma in both patient populations, and assessed whether stratification by pathologic extent of local disease would yield an equivalent outcome.

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER

PURPOSEnWe determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.nnnMATERIALS AND METHODSnThe clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.nnnRESULTSnOf 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.nnnCONCLUSIONSnThe guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.

TRANSIENT LOWER EXTREMITY NEURAPRAXIA ASSOCIATED WITH RADICAL PERINEAL PROSTATECTOMY: A COMPLICATION OF THE EXAGGERATED LITHOTOMY POSITION

PURPOSEnWe assess the incidence and risk factors associated with lower extremity neurapraxia following radical perineal prostatectomy.nnnMATERIALS AND METHODSnThe medical records of 111 consecutive patients undergoing radical perineal prostatectomy at Duke University Medical Center between June 1994 and June 1995 were retrospectively reviewed. Patients were interviewed by telephone to ascertain whether symptoms had resolved.nnnRESULTSnNeurapraxia developed in 23 patients (21%). Symptomatology was variable, including sensory and motor deficits of the lower leg and foot. Although lower extremity neurapraxia occurred in a significant number of patients undergoing radical perineal prostatectomy, it appeared to resolve in most.nnnCONCLUSIONSnCareful attention to detail when positioning the patient and limiting the time in the exaggerated lithotomy position appear to be the most critical aspects to prevent neurapraxia.

Treatment options, selection, and satisfaction among african american and white men with prostate carcinoma in north carolina

In the U.S., prostate carcinoma mortality is greatest among African Americans. In North Carolina, the state with the fourth largest population of African Americans, the prostate carcinoma mortality rate is 2.5 times greater among African Americans than among whites and is the highest reported rate for any state in the nation. To explore potential reasons for the racial differential in mortality, a study was undertaken to determine whether differences related to treatment existed between African American and white men who were diagnosed with prostate carcinoma during the period 1994‐1995.

Transvaginal repair of vesicovaginal fistulas after hysterectomy by vaginal cuff excision

PURPOSEnWhen repairing vesicovaginal fistulas after hysterectomy there is often reluctance to excise totally the fistula tract for fear of enlarging the tissue defect. It has been suggested that consequent tension on suture lines may cause recurrence of an even larger fistula. On the other hand, a basic surgical principle is that scar tissue margins will not heal as quickly or at all compared to fresh viable margins. We reviewed whether our technique of total excision of the fistula tract and vaginal cuff scar provides an efficient cure rate.nnnMATERIALS AND METHODSnWe retrospectively analyzed the outcomes of 20 women who underwent vaginal cuff excision repairs of a vesicovaginal fistula after total hysterectomy. Women who had complex fistulas and/or prior radiation therapy were excluded from study.nnnRESULTSnOf the 20 patients 3 (15%) sustained a bladder lesion that was repaired intraoperatively and 7 (35%) underwent 1 or more attempts at secondary repair. All fistulas were at the vaginal cuff. Mean fistula size was 0.7 cm. (11 women). All repairs were performed as soon as possible after presentation except 2 (10%) that were delayed because of the fistula appearance. The fistula tract was excised totally in all patients. All patients were cured. There were no postoperative complications and no significant or symptomatic vaginal shortening.nnnCONCLUSIONSnTransvaginal vaginal cuff excision repair is an effective first attempt cure of vesicovaginal fistulas after hysterectomy. Excision of the fistula tract and vaginal cuff scar enables the surgeon to suture viable tissues in every layer, thereby providing conditions optimal for wound healing. This procedure obviates the need to wait for tissue readiness and to interpose a flap in the majority of patients.

Dorsal onlay urethroplasty for urethral stricture repair

Abstract Full-thickness penile skin grafts have long proved to be valuable in substitution urethroplasty. However, occasional cases of poor graft take, sacculation, or shrinkage of the repairs have mitigated their success. A determining factor in the outcome of grafts is their mechanical support. Historically, ventral placement of the graft has been used, primarily because of the simplicity of access and the excellent graft bed offered by the spongy tissue. However, mechanical support in this location is suboptimal in comparison with that offered by the corpora cavernosa. Recently, dorsal placement of the graft has been proposed, allowing the skin patch to be spread fixed on the tunica albuginea of the corporal bodies overlying the stricture. Fixation of the graft may minimize its retraction and increase its neovascularization. To date, this innovation has proved to be very promising.