Christopher E. Wolter

The Evolution of Obstruction Induced Overactive Bladder Symptoms Following Urethrolysis for Female Bladder Outlet Obstruction

PURPOSE Bladder outlet obstruction following stress incontinence surgery may present as a spectrum of lower urinary tract symptoms. We evaluated the prevalence and impact of persistent overactive bladder symptoms following urethrolysis for iatrogenic bladder outlet obstruction. MATERIALS AND METHODS In a retrospective review we identified 40 patients who underwent urethrolysis. All patients underwent a standardized urological evaluation. Patients identified with genitourinary erosion, neurogenic bladder dysfunction and preexisting overactive bladder were excluded. Urethrolysis outcomes were determined by subjective bladder symptoms and objective parameters. Validated questionnaires were completed to assess symptom bother, patient satisfaction and quality of life. Statistical analyses were performed using Stata, version 9.0. RESULTS A total of 40 patients were included in the study with a mean +/- SD followup of 13 +/- 11 months (range 3 to 38). Of the patients 34 patients presented with obstructive symptoms, while 36 had overactive bladder symptoms. Obstructive symptoms resolved in 28 of the 34 patients (82%), while overactive bladder symptoms resolved completely in only 12 (35%) and they were significantly improved in 4 (12%). Overall 20 patients (56%) were on antimuscarinics for refractory overactive bladder and 8 ultimately required sacral neuromodulation. Pre-urethrolysis detrusor overactivity was more likely in patients with persistent overactive bladder symptoms than in those in whom overactive bladder symptoms resolved (70% vs 38%). Patients with persistent overactive bladder had significantly greater symptom severity/bother, and decreased perception of improvement and quality of life following urethrolysis. CONCLUSIONS Following urethrolysis overactive bladder symptoms may remain refractory in 50% or greater of patients, which has a negative impact on quality of life and the impression of improvement after surgery. Detrusor overactivity demonstrated preoperatively may be useful for predicting who may have persistent overactive bladder symptoms despite an effective urethrolysis procedure.

Genitourinary Fistula Experience in Sierra Leone: Review of 505 Cases

PURPOSE We reviewed cases of genitourinary fistula resulting from birth trauma in Sierra Leone to determine factors predictive of successful operative repair. MATERIALS AND METHODS A total of 505 operative repairs of genitourinary fistula were completed at 2 centers in Sierra Leone from 2004 to 2006. Statistical analysis of patient demographics, fistula characteristics, outcomes and surgical complications was performed. RESULTS Primary repairs, defined as the first repair, accounted for 68% of repairs in the population with 92% classified as vesicovaginal fistula alone. Only 56% of women were deemed to have an intact urethra at presentation and 68% were diagnosed with moderate or severe fibrosis surrounding the fistula. On univariate analysis parameters that demonstrated significant differences with primary operative success were patient age at fistula occurrence (p = 0.0192), index pregnancy (p = 0.0061), location (p <0.0001), surface area (p <0.0001), urethral status (p <0.0001) and fibrosis (p <0.0001). On multivariate analysis the fistula parameter that correlated with successful repair was the extent of fibrosis (severe fibrosis OR 3.7). CONCLUSIONS Genitourinary fistula as a result of prolonged obstructed labor is a cause of considerable morbidity in sub-Saharan Africa, including Sierra Leone. The most profound factor correlating with a positive operative outcome was the extent of fibrosis surrounding the fistula. These data are important to help predict the likelihood of successful repair and assist in selecting women for the appropriate surgical procedure.

Removal of Transobturator Midurethral Sling for Refractory Thigh Pain

Polypropylene midurethral slings have become the most common surgical procedure for the treatment of stress urinary incontinence. The efficacy has been well established through prospective and systematic evaluation. Transobturator midurethral slings have demonstrated comparable efficacy relative to the retropubic approach with the potential to minimize the morbidity associated with retropubic needle passage. We present a case of recalcitrant medial thigh pain after transobturator midurethral sling placement that ultimately required medial thigh/transobturator exploration and sling excision.

Insertion of Double-J Stent

This common procedure is indicated in a variety of settings in urology. Its general indication is to relieve obstruction of the ureter. This can be caused by a variety of conditions. Obstruction by a calculus, ureteral stricture, extrinsic compression, and ureteropelvic junction obstruction are just a sample of the conditions this procedure can be employed in. In addition, double-J stents (Figure 29.1) can be placed before other pelvic surgeries to aid in identifying the ureter, though simple ureteral catheters can be used for this as well. Finally, double-J stents can be placed after other reconstructive urologic procedures such as ureteral reimplant, pyeloplasty, or partial nephrectomy. Here we will describe the basic technique employed in placing the double-J stent (double pigtail ended stent on both ends). Open image in new window Figure 29.1. One End of a Double-J Stent With Black Mark.

Extracorporeal Shockwave Lithotripsy (ESWL)

ESWL has proven over time to be a major breakthrough in urology. It is the procedure by which shockwaves are generated at a point external to the body (F1 point) and are focused on a kidney stone in the body (F2 point) (Figure 28.1). The shockwaves themselves are relatively weak at their source and can thus traverse the body without any untoward effects. However, at the point at which they are focused, they are sufficiently powerful to fragment a kidney stone. This is guided by fluoroscopy in most instances, though ultrasound-guided techniques have been described. Fragmenting almost any stone can be attempted with this technique, but the success varies greatly depending on the size and location of the stone. Generally speaking, for stones in the upper and interpolar calyces, and the renal pelvis, the size limit is 2 cm, and for stones in the lower pole, the size limit is 1 cm. Most stones in the upper ureter can be fragmented as well. The larger the stone, the higher the likelihood there will be a need for a second procedure. Contraindications to this procedure include active urinary tract infection, uncontrolled bleeding diathesis, poorly controlled hypertension, and pregnancy. Relative considerations that may prohibit use of ESWL are obesity, deformity of body habitus, suspected anatomic obstruction, stones in a calyceal diverticulum, and renal failure. Open image in new window Figure 28.1. F1 and F2 Points.