Donatella Pistolesi

Polypropilene Sling of the Bulbar Urethra for Post-Radical Prostatectomy Incontinence

OBJECTIVE We present details of a modification of the Stamey procedure using a polypropilene mesh to compress the corpus spongiosum of the bulbar urethra in the treatment of sphincteric incompetence following radical prostatectomy. MATERIALS AND METHODS Between September 1999 and June 2000 nine patients 66-80 years old (mean age 74) with severe incontinence due to radical prostatectomy underwent the bulbourethral sling procedure with polypropilene (Prolene) mesh implant. After transperineal incision a 5cmx4cm rectangular prolene mesh was placed against the bulbar urethra and suspended by four prolene sutures transferred to a suprapubic incision through ligature carriers as in the four corner bladder and bladder neck suspension. If leakage recurred in the follow-up, a retightening procedure was performed in local anesthesia rescuing the prolene threads over a polypropilene mesh placed against the rectus fascia. Mean follow-up was 14 months (range 12-20). Continence status and post-void residual volume were evaluated after 1, 3 and 6 months post-operatively and successively every 3 months. RESULTS At the present follow-up considering the results of the retightening procedure five out of nine patients were cured, two out of nine improved and two were unchanged. Five out of nine patients reported slight to mild perineal/genital discomfort which disappeared in four at three months post-operatively. No patients required mesh removal for complications. CONCLUSIONS The male bulbourethral sling procedure using a polypropilene mesh is safe but further experience is needed to establish this procedure as plausible alternative for the treatment of post-radical prostatectomy urinary incontinence.

Hyperbaric oxygen therapy in BKV-associated hemorrhagic cystitis refractory to intravenous and intravesical cidofovir: Case report and review of literature

Hemorrhagic cystitis is a common complication in hematopoietic stem cell transplant recipients. We report here a case of severe BKV-associated hemorrhagic cystitis who did not respond to intravenous cidofovir. Overt hematuria successfully resolved after a few days on hyperbaric oxygen and intravesical instillations of cidofovir, while BK viruria dropped after a few weeks and remained low. We review the literature for therapeutic options in hemorrhagic cystitis and try to explain how hyperbaric oxygen stimulates mucosal repair in the urinary bladder.

Systematic review of surgical treatment of post radical prostatectomy stress urinary incontinence

Context Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient quality of life and other critical postoperative outcomes.

Orgasm-Associated Incontinence (Climacturia) after Bladder Neck-Sparing Radical Prostatectomy: Clinical and Video-Urodynamic Evaluation

INTRODUCTION Orgasm-Associated Incontinence (OAI) or climacturia has been observed in male patients maintaining sexual potency after radical prostatectomy and cystectomy. AIM We investigated the incidence and video-urodynamic aspects of this event in continent and potent patients after bladder neck-sparing (BNS) radical prostatectomy (RP). MAIN OUTCOME MEASURE Comparing functional and morphological aspects between climacturic and non-climacturic patients to identify a possible explanation of this unusual kind of leakage that could seriously impact the sexual life after surgery. METHODS In a pool of 84 men, potent and continent at least 1 year after BNS RP, 24 (28.6%) reported climacturia and 7 agreed to undergo video-urodynamic evaluation (group 1), which was performed also in 5 controls (group 2). Those 12 men were also evaluated with 24-hour pad test, 5-item International Index of Erectile Function and International Prostate Symptom Score questionnaires. RESULTS Functional urethral length (FUL) was significantly lower in the climacturia group (P=0.02) and time to continence recovery was significantly longer (P=0.05). No other significant differences were found between the two groups. The radiological appearance of the vesicourethral junction at voiding cystourethrography was similar. CONCLUSIONS To the best of our knowledge, this is the first functional and morphological evaluation of climacturia after RP. In our experience, this event is indirectly associated with a reduced FUL in the sphincter area, although both patients and controls were continent during daily activities. BNS technique seems to reduce time to continence recovery, although climacturic patients need longer time than control patients. Since in our series no rigidity of the vesicourethral anastomosis was radiographically evident, we believe that differences in FUL could explain OAI. Anatomical difference in membranous urethra length could explain the occurrence of this symptom in patients treated with the same surgical technique.

Recurrent Pseudodiverticula of Female Urethra: Five-year Experience

OBJECTIVES To report our experience of transvaginal diverticulectomy with pubovaginal sling placement in a series of 32 women with recurrent urethral pseudodiverticula. METHODS A total of 32 women underwent surgical repair from January 2000 to June 2007. Of the 32 women, 12 had undergone other concomitant previous urethral surgery, predominantly for stress urinary incontinence. Transvaginal excision of the diverticulum and concomitant pubovaginal sling placement were performed routinely. The women were evaluated postoperatively for symptom relief, anatomic result, and postoperative continence status at 1, 6, and 12 months and annually thereafter. Pelvic magnetic resonance imaging was repeated after 1 year. RESULTS The mean follow-up was 4.3 years. In all cases, the voiding urethrogram after catheter removal showed a good urethral shape with an absence of urinary leaks. At the postoperative urodynamic investigation, 27 patients had an unobstructed and 5 an equivocal Blaivas-Groutz nomogram. Three patients (20%) reported a persistent degree of stress urinary incontinence, including 2 with grade 1 stress urinary incontinence and 1 with mixed incontinence. Two patients presented with clinically evident diverticulum recurrence, and in 1 patient, an intraurethral diverticulum, was found at the 1-year magnetic resonance imaging examination. CONCLUSIONS A pubovaginal sling added routinely to all diverticulectomy procedures offers significant support to the urethral repair and/or prevention of urinary incontinence, including in recurrent cases, and does not increase the risk of erosion into the urethra or fistula formation.

Should We Stop Using Botulinum Neurotoxin Type A in Patients With Neurogenic Detrusor Overactivity After Development of Secondary Resistance

Botulinum neurotoxin (BoNT) injection into the bladder is a commonly accepted treatment option for patients with refractory idiopathic or neurogenic detrusor overactivity [1]. To date, of the seven naturally occurring BoNT serotypes, only two (ie, A and B) are available for clinical use. BoNTA, which is commercialised in three formulations (abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA), is more commonly used than BoNTB (rimabotulinumtoxinB) because of higher potency and longer duration of action, as indicated by electromyographic evaluation [2]. The therapeutic benefits obtained by BoNT injection are not permanent, and periodic injections are needed. However, some patients do not respond or have a decreased response after repeat injections. In cases of BoNTA failure, injection of BoNTB may be an option. We [3] and Reitz and Schurch [4] first reported a good response with rimabotulinumtoxinB in one patient and two patients, respectively, with neurogenic detrusor overactivity who developed secondary resistance to abobotulinumtoxinA and onabotulinumtoxinA, as assessed by the extensor digitorum brevis (EDB) test. Since then, no further report of patients treated with BoNTB after resistance to BoNTA has been published, and midand long-term follow-up of patients treated with BoNTB is unknown. Although headto-head comparisons between BoNT serotypes are lacking, the few available studies in the urologic literature seem to suggest that BoNTB has a shorter duration of effect and is associated with a higher rate of adverse events, mainly autonomic, due to a presumed higher affinity for autonomic nerve endings, compared with BoNTA [5]. We now report the follow-up of a small series of patients receiving rimabotulinumtoxinB after abobotulinumtoxinA, with the unique finding so far of the recovery of sensitivity to abobotulinumtoxinA in one patient with previously proven resistance. Using rimabotulinumtoxinB, we treated a total of four patients with refractory neurogenic detrusor overactivity who had experienced complete secondary failure to abobotulinumtoxinA 1000 IU per session. Before injecting rimabotulinumtoxinB, an EDB test was performed with both neurotoxins in all patients to evaluate their respon-

Videourodynamics in patients with neurogenic bladder due to multiple sclerosis: our experience

PurposeThe aims of this study were to: (a) analyse the most frequent morphofunctional features of the lower urinary tract observed during videourodynamic examination in patients with neurogenic bladder due to multiple sclerosis; (b) investigate the role of the videourodynamic examination in the clinical management of these patients; and (c) demonstrate the relationship between morphological and functional variables.Materials and methodsWe performed videourodynamic examinations in 75 patients affected by neurogenic bladder secondary to multiple sclerosis.ResultsThe introduction of pharmacological therapy, based on clinical and functional evaluation of the lower urinary tract, is correlated with satisfactory morphofunctional outcomes, reducing moderate-to-severe postvoid residual (PVR; p < 0.1) and compliance (p < 0.05) at the price of reduced bladder sensation. Clinical management of these patients based on morphological evaluation of the lower urinary tract decreased the occurrence of detrusor-sphincter dyssynergy (DSD) and detrusor overactivity incontinence at the following examination.ConclusionsOur study confirmed a relationship between detrusor overactivity and hypertonic bladder, bladder diverticula, vesicoureteral reflux, between detrusor underactivity and PVR and between DSD and bladder diverticula. Our data show how the videourodynamic examination may improve evaluation and urological management of these patients.RiassuntoObiettivoQuesto studio è stato condotto con un triplice obiettivo: analizzare i reperti morfo-funzionali vescicosfinterici più frequentemente rilevati con l’esame video-urodinamico in pazienti con vescica neurologica secondaria a sclerosi multipla, studiare il ruolo di questo esame nella loro gestione clinica e dimostrare l’esistenza di un rapporto di dipendenza tra variabili funzionali e morfologiche.Materiali e metodiSono stati studiati 75 pazienti con vescica neurologica secondaria a sclerosi multipla mediante l’esecuzione dell’esame video-urodinamico.RisultatiL’introduzione della terapia farmacologica basata sulla valutazione clinica e funzionale dell’unità vescico-sfinterica consente di ottenere risultati morfofunzionali buoni, con il miglioramento del residuo postminzionale (RPM) moderato-severo (p<0,1) e della compliance (p<0,05), a scapito della sensibilità vescicale (p<0,1). La gestione clinica dei pazienti basata anche su valutazioni morfologiche del basso tratto urinario consente di ottenere risultati statisticamente migliori, con la riduzione dei casi di dissinergia detrusore-sfintere esterno (DESD) e iperattività detrusoriale con fuga di urina nell’esame di controllo.ConclusioniI dati ottenuti da questo studio consentono di dimostrare l’esistenza di un rapporto di causalità tra iperattività detrusoriale e ipertono parietale, diverticoli vescicali e reflusso vescico-ureterale (RVU), tra ipoattività detrusoriale e RPM, e tra DESD e diverticoli vescicali; permettono inoltre di avvalorare l’utilità dell’esame videourodinamico nella valutazione e nel management urologico di questi pazienti.

Artificial Sphincters to Manage Urinary Incontinence: A Review: ARTIFICIAL SPHINCTERS TO MANAGE UI

Urinary incontinence affects more than 300 million people worldwide. The implantation of a medical device called an artificial urinary sphincter (AUS) is the gold standard treatment when conservative and minimally invasive therapies fail. In this article, the AUSs (extra-urethral and endo-urethral sphincters) available on the market, both presented at the research level and filed as patents, are reviewed. The ability of the different solutions to effectively replace the natural sphincter are discussed, together with advantages and some possible side effects, such as tissue atrophy, overall invasiveness of the implant, and so forth. Finally, future research priorities are discussed for both endo-urethral and extra-urethral approaches considering key engineering aspects, such as materials, compression and closure mechanisms, and implantation methods, with the long-term aim of developing an effective, reliable, durable, and minimally invasive AUS capable of restoring a normal quality of life for incontinent patients.

Clinical Assessment and Other Instrumental Examinations

The aetiology of male stress urinary incontinence (SUI) may be partly associated with demographic factors, for example aging and obesity [1], but it is also linked to the growing common treatment of prostate diseases.

Continence Physiology and Male Stress Incontinence Pathophysiology

Neurophysiologic function of the continence mechanism in the male has been largely focused on voiding difficulties and directed to explore the obstruction instead of incontinence. Over the past 20 years, much has been elucidated about the pathophysiology of male SUI. As improved diagnostic modalities have provided new insight into the function and dysfunction of the urethral continence mechanism, theories have evolved from being purely anatomic to being both functional and anatomic.