Delbert C. Rudy

Urodynamic Evaluation of incontinence in Patients Undergoing Modified Campbell Radical Retropubic Prostatectomy: A Prospective Study

A prospective urodynamic study was performed on 17 consecutive patients undergoing a modified Campbell radical retropubic prostatectomy for prostatic carcinoma. There was 1 postoperative death, leaving 16 evaluable patients. Patients were evaluated preoperatively and at 6 weeks, 3 months and 6 months postoperatively. The only urodynamic parameter 6 months postoperatively that differed significantly from the preoperative value was the functional urethral length, 1.6 and 4.3 cm., respectively. The incidence of clinical and/or urodynamic urinary incontinence preoperatively was 19 per cent and 6 months after the procedure it was 87 per cent. The incontinence rate did not correlate with the pathological stage or histological grade of the tumor. There was a strong trend toward improvement of continence with time but all patients who were incontinent 6 months postoperatively and followed for more than 1 year remained incontinent. While this incontinence rate is the highest reported, we believe that it reflects detailed patient interviews and objective fluoroscopic evidence of urethral urinary loss. These results and those of others suggest that modification of the technique of radical prostatectomy to produce a functional urethral length of at least 2.8 cm. may be desirable.

Voiding and erectile function after delayed one-stage repair of posterior urethral disruptions in 50 men with a fractured pelvis

We evaluated 50 men who suffered a total disruption of the posterior urethra in conjunction with a fractured pelvis. The urethral disruption was treated with immediate placement of a suprapubic cystostomy and delayed one-stage urethroplasty. Subsequently, 15 required at least one visual urethrotomy and three underwent one urethral dilatation. All 50 now have a patent urethra and 38 (76%) void normally and are continent. Five have an areflexic bladder secondary to the injury and intermittently catheterize themselves but are continent. Three patients have mild urge incontinence and three mild stress incontinence, not requiring treatment or protection. One patient with an open bladder neck has moderate stress incontinence which has responded to imipramine therapy. Impotence was present both preoperatively and postoperatively in 24 (48%) of the patients but by one year only 16 (32%) of them were still not having erections. Eighteen patients (36%) claim to have erections equal to their pre-injury quality. However, 16 (32%) of the patients, although potent and able to have intercourse, have less than optimal erections.

Time to onset of improvement in symptoms of overactive bladder using antimuscarinic treatment

To evaluate the time to onset of statistically significant and clinically meaningful effects of trospium chloride in patients with an overactive bladder (OAB).

Simple cyst of the testis.

We report 5 cases of simple cyst of the testis, the largest series to date, and review the literature. Included are 2 autopsy cases, a case of a multilocular simple cyst and 1 case treated nonoperatively. Based on our experience, simple cyst of the testis should be suspected particularly in an enlarged but otherwise palpably normal testis. High resolution real-time scrotal sonography revealing an anechoic mass in the testis with well defined walls, and enhanced posterior through transmission and edge shadowing is diagnostic for a simple cyst. An asymptomatic simple cyst of the testis may be treated with observation alone. The symptomatic simple cyst should be treated ideally with local parenchyma-sparing excision.

Segmental renal artery emboli treated with low-dose intra-arterial streptokinase

Herein we describe a sixty-one-year-old man with unilateral segmental renal artery emboli treated with renal intra-arterial streptokinase infusion. The initial infusion rate was 9,000 units/hr. which was decreased to 5,000 units/hr. over the next six hours. Periodic arteriography demonstrated progressive lysis and virtual complete resolution after fifty-two hours of infusion. Intravenous pyelogram (IVP) six weeks later showed almost complete return of functional compared with IVP obtained six years earlier. We have demonstrated successful clot lysis at an infusion rate of 5,000 units/hr., compared with reported rates of 25,000 units/hr. and without the frequently utilized initial large intravenous bolus. Such low-dose streptokinase infusion should, theoretically, limit the incidence of recognized dose-related complications and permit its use in clinical settings where higher dosages are contraindicated. Intra-arterial streptokinase therapy seems particularly suitable for the high surgical risk patient and in arterial lesions not amenable to surgery. The availability of this potentially efficacious therapy suggests that aggressive diagnostic studies be pursued early in patients suspected of having an acute renal arterial embolus.

Pharmacokinetics of Oxybutynin Chloride Topical Gel

AbstractBackground: Oxybutynin chloride topical gel (OTG; Gelnique®) is an approved formulation for the transdermal administration of oxybutynin, an established antimuscarinic therapy for overactive bladder (OAB). Transdermal administration of oxybutynin minimizes plasma concentrations of the active metabolite N-desethyloxybutynin (N-DEO), which can have anticholinergic adverse effects. Objectives: In four phase I studies, we separately assessed the effects of OTG application site selection on oxybutynin bioavailability (site-to-site study); the effects of post-application showering on oxybutynin steady-state pharmacokinetics (showering study); the effects of sunscreen application on oxybutynin absorption (sunscreen study); and the person-to-person transfer of oxybutynin through skin-to-skin contact at the application site (transference study). Methods: All four studies were open-label, randomized, phase I studies. The site-to-site and showering studies involved repeated administration of OTG to establish steady-state plasma concentrations of oxybutynin and N-DEO; the other two studies involved single doses. Clinical visits were required for pharmacokinetic sampling, supervision of OTG self-application on pharmacokinetic sampling days, showering, sunscreen application and transference experiments. The study included healthy subjects aged 18–45 years. Subjects with conditions requiring medical therapy or interfering with the application of OTG or the interpretation of pharmacokinetic results were excluded. Participants applied OTG (1 g containing oxybutynin chloride 10%, 1.14 m L/dose) once daily to the abdomen, upper arm/shoulder or thigh. Showering occurred 1–6 hours after dosing. Sunscreen was applied 30 minutes before or after OTG application. Abdomen-to-abdomen contact with movement for 15 minutes between treated and untreated participants was conducted 1 hour after dosing. Time points of serial blood sampling for pharmacokinetic analyses varied among studies. Plasma concentrations of oxybutynin and N-DEO (except transference study) were measured. Bioequivalence was tested with ANOVA models for loge-transformed plasma exposure (area under the plasma concentration-time curve [AUC]) and maximum plasma concentration (Cmax) to generate 90% confidence intervals (CIs). Results: Oxybutynin and N-DEO exposures (AUCs) from time zero to 24 hours (AUC24) were similar for the three application sites, with N-DEO/ oxybutynin mean AUC24 ratios of approximately 0.9. The 90% CIs for thigh-to-abdomen ratios of oxybutynin AUC24 (0.93, 1.23) and Cmax(0.85, 1.16) were within the interval required for bioequivalence (0.8, 1.25); the other application site ratios for oxybutynin had boundaries slightly outside this interval. Showering 1–6 hours and sunscreen application 30 minutes before or after OTG application had minor effects on oxybutynin concentrations. After vigorous skin contact between treated and untreated participants at the application site, the mean± SD AUC from time zero to 48 hours (AUC48) of oxybutynin in 12 untreated participants was 29.8 ± 24.5 ng · h/mL, approximately one-quarter of the exposures generally seen in subjects treated with a single dose of OTG. Oxybutynin AUC48 after clothing-to-skin contact was undetectable in 12 of 14 untreated participants and very low (mean ± SD 0.4 ± 0.8 ng · h/mL) in two untreated female participants. Conclusion: The bioavailability of oxybutynin and its pharmacokinetic profile are not greatly affected by application site selection, post-application showering or sunscreen use shortly before or after dosing with OTG. Oxybutynin transference to untreated persons is essentially prevented by avoiding direct skin-to-skin contact with the application site.

Adult respiratory distress syndrome complicating percutaneous nephrolithotripsy

In an otherwise healthy thirty-six-year-old man adult respiratory distress syndrome developed following percutaneous nephrolithotripsy. Absorption of a large volume of irrigating solution occurred during the procedure and resulted in respiratory compromise, neither of which was appreciated intraoperatively. Close intraoperative monitoring of irrigation fluid input and output is necessary, and if a significant discrepancy develops, we believe the procedure should be terminated and diuresis instituted. In a difficult procedure, consideration should be given to establishing a maximum operating time and shortened if patient risk factors so warrant.

Familial Juvenile Type III Spinal Cord Arteriovenous Malformation: Urodynamic Findings

Two sisters with juvenile type III spinal cord arteriovenous malformations were studied urodynamically. Micturitional dysfunction was prominent in the clinical presentation of both cases. Although both patients had similar lesions 1 demonstrated detrusor-sphincter dyssynergia and detrusor hyperreflexia, while the other showed only detrusor hyperreflexia. This is the first report of a familial occurrence of juvenile type III arteriovenous malformation and of the associated urodynamic findings.

Effects of Oxybutynin Chloride Topical Gel on Health-Related Quality of Life in Adults with Overactive Bladder: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: Oxybutynin chloride topical gel (OTG) significantly improved overactive bladder (OAB)–related urinary symptoms and was well tolerated in a phase III double-blind, placebo-controlled trial (ClinicalTrials.gov identifier NCT00350636). This study further evaluated the effect of OTG on health-related quality of life (HRQoL) in adults with OAB. Methods: Adults aged 18 years or older with urge-predominant urinary incontinence were assigned randomly to OTG 1 g/day or matching placebo for 12 weeks. HRQoL was measured by the Incontinence Impact Questionnaire (IIQ) and the King’s Health Questionnaire (KHQ) at baseline and at weeks 1, 4, 8, and 12. Between-group differences in IIQ or KHQ score changes from baseline to week 12 or last observation were compared by analysis of covariance. Results: Of 789 study participants (704 women, 85 men), 389 received OTG and 400 received placebo. Mean age was 59 ± 12 years. IIQ total score improved significantly more in participants treated with OTG (P = 0.0005) than in those treated with placebo, as did scores on all four IIQ subscales: Emotional Health (P = 0.0002), Social Relationships (P = 0.0019), Travel (P = 0.0068), and Physical Activity (P = 0.0078). KHQ scores improved significantly more with OTG than with placebo in the more incontinence-specific domains: Incontinence Impact (P = 0.0023), Symptom Severity (P = 0.0024), Severity (Coping) Measures (P = 0.0058), Sleep/Energy (P = 0.0061), Role Limitations (P = 0.0133), and Personal Relationships (P = 0.0489). Conclusion: Treatment with OTG resulted in significant HRQoL improvements in adults with OAB.