Fawzy Farag

Pathophysiology and Contributing Factors in Postprostatectomy Incontinence: A Review

CONTEXTnThe incidence and awareness of postprostatectomy incontinence (PPI) has increased during the past few years, probably because of an increase in prostate cancer surgery. Many theories have been postulated to explain the pathophysiology of PPI.nnnOBJECTIVEnThe current review scrutinizes various pathophysiologic mechanisms underlying the occurrence of PPI.nnnEVIDENCE ACQUISITIONnA search was conducted on PubMed and EMBASE for publications on PPI. The primary search returned 2518 publications. Animal and basic research studies, letters, publications on prostatectomy for benign reasons, pathology of prostatic carcinoma, radiotherapy and hormone therapy of prostatic carcinoma, and review articles were all used as criteria for exclusion from the study. A total of 128 publications were selected for final analysis.nnnEVIDENCE SYNTHESISnNeuromuscular anatomic elements and pelvic support are known to influence PPI as evidenced by multiple publications. A number of non-anatomic and surgical elements have been postulated as contributing factors to PPI. Biological factors and preoperative parameters include: functional bladder changes, age, body mass index (BMI), pre-existing lower urinary tract symptoms (LUTS), prostate size, and oncologic factors. Multiple studies reported the impact of specific anatomic/surgical factors, including fibrosis, shorter membranous urethral length (MUL), anastomotic stricture, damage to the neurovascular bundle, and extensive dissection, all of which have a negative impact on the continence status of patients following radical prostatectomy (RP). Investigation of the impact of techniques to spare the bladder neck and additional procedures to reconstruct the posterior or anterior support structures (eg, the Rocco stitch) on continence status is ongoing.nnnCONCLUSIONSnAnatomic support and pelvic innervation appear to be important factors in the etiology of PPI. Biological/preoperative factors including greater age at time of surgery, pre-existing LUTS, high BMI, shorter MUL, and functional bladder changes have a negative impact on continence after RP. Extensive dissection during surgery, damage to the neurovascular bundle, and postoperative fibrosis also have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior fixation of the bladder-urethra anastomosis are associated with better continence rates. There is still debate about whether posterior pelvic reconstruction leads to better postoperative continence rates.nnnPATIENT SUMMARYnRadical prostatectomy is an oncologic procedure and thus requires removal of the entire prostate gland and seminal vesicles, ideally with negative surgical margins. This sometimes results in urinary incontinence. The factors contributing to urinary incontinence are explained in this article.

Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes

There are many opinions but little firm knowledge about the optimal treatment of neurogenic stress urinary incontinence (NSUI).

Circumferential urinary sphincter surface electromyography: A novel diagnostic method for intrinsic sphincter deficiency

The diagnosis of intrinsic sphincter deficiency (ISD) in patients with stress urinary incontinence (SUI) is not well established. We explored the possibility of applying a new tool: minimally invasive circumferential sphincter surface electromyography (CSS‐EMG) to assess the muscular integrity of the urethral sphincter in patients with SUI/ISD.

Single session vs two sessions of flexible ureterosopy (FURS) for dusting of renal pelvic stones 2-3 cm in diameter: Does stone size or hardness play a role in number of sessions to be applied?"

OBJECTIVEnTo evaluate the stone hardness in predicting the need for single or two sessions of retrograde intrarenal surgery (RIRS) for renal pelvis stones of 2-3 cm in size.nnnMATERIAL AND METHODSnNinety-six patients (64 male and 32 female) with only renal stones (2.5±0.3 cm) underwent RIRS using flexible 7.5 Fr ureteroscope (FURS). The stone hardness was evaluated by preoperative non-contrast computed tomography (NCCT). The patients were divided into two groups based on stone hardness: Group I (n=54) (hard stones - Hounsfield Unit (HU) >1000) and group II (n=42) (not hard stone - HU <1000). The stone-free rate, the operative time, any intra or postoperative complications and the need for second sessions of RIRS were evaluated.nnnRESULTSnAll stones were successfully accessed. Intraoperative complications were not reported. The initial stone-free rate was 40% in Group I and 95% in Group II after a single session (p=0.01). A second session FURS was needed in 32 cases of Group I (40%) where postoperative CT showed significant residual stone fragments of 6±2 mm, and stone-free rate up to 100 percent. On the contrary only 2 cases from Group II underwent second session FURS (p=0.01). The operative times were 75±15 minutes in Group I and 55±13 minutes in Group II (p<0.01). Six patients (4 in group I and 2 in group II) had postoperative high-grade fever (Clavien Grade II).nnnCONCLUSIONnStone hardness had a significant impact on the decision of performing single versus two sessions of FURS for renal pelvic stones of 2-3 cm rather than the stone size alone.

Decline in artificial urinary sphincter survival in modern practice-Do we treat a different patient?

Over the past few years, we have been doing an increasing number of revisions for artificial urinary sphincters (AUS) at our center. The study aims to investigate reason for this change in our practice.

A novel algorithm for the non-invasive detection of bladder outlet obstruction in men with lower urinary tract symptoms

Abstract Objective: To determine the ability of bladder wall thickness (BWT) in combination with non-invasive variables to distinguish patients with bladder outlet obstruction (BOO). Patients and methods: Patients completed the International Prostate Symptom Score (IPSS) questionnaire and prostate size was measured by transrectal ultrasonography (US). Pressure-flow studies were performed to determine the urodynamic diagnosis. BWT was measured at 250-mL bladder filling using transabdominal US. Recursive partition analysis (RPA) recursively partitions data for relating independent variable(s) to a dependent variable creating a tree of partitions. It finds a set of cuts of the dependent variable(s) that best predict the independent variable, by searching all possible cuts until the desired fit is reached. RPA was used to test the ability of the combined data of BWT, maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), IPSS, and prostate size to predict BOO. Results: In all, 72 patients were included in the final analysis. The median BWT, voided volumes, PVR, mean Qmax, and IPSS were significantly higher in patients who had an Abrams/Griffiths (A/G) number of >40 (55 patients) compared to those with an A/G number of ≤40 (17 patients). RPA revealed that the combination of BWT and Qmax gave a correct classification in 61 of the 72 patients (85%), with 92% sensitivity and 65% specificity, 87% positive predictive value, and 76% negative predictive value (NPV) for BOO (area under the curve 0.85). The positive diagnostic likelihood ratio of this reclassification fit was 2.6. Conclusions: It was possible to combine BWT with Qmax to create a new algorithm that could be used as a screening tool for BOO in men with lower urinary tract symptoms.

Urethroplasty for treatment of long anterior urethral stricture: buccal mucosa graft versus penile skin graft-does the stricture length matter?

AbstractPurposeTo investigate the surgical outcomes of dorsal onlay urethroplasty (DOU) using buccal mucosa graft (BMG) or penile skin graft (PSG) and to assess the effect of stricture length in men with anterior urethral strictures.MethodsA prospective cohort included men with anterior urethral strictures between 2008 and 2015. Patients underwent DOU using PSG or BMG. Patients had urethrography and uroflowmetry at 0, 3, 6, 12xa0months, and urethroscopy when needed. Student’s t test, Mann–Whitney U tests, and Pearson’s Chi-square test were used for analysis.ResultsSixty-nine patients (43xa0±xa014xa0year) were included, 31 received BMG, and 38 received PSG. Mean stricture length was 8xa0±xa03xa0cm, mean operative time was 145xa0±xa031xa0min, and mean follow-up was 56xa0±xa010xa0mo. Success rate was 87xa0% (90xa0% BMG vs. 84xa0% PSG, pxa0=xa00.4). Mean operative time was significantly shorter in PSG group (136xa0±xa029xa0min vs. 256xa0±xa058xa0min, pxa0=xa00.0005). Complications of grade I developed in 36xa0% (wound infectionxa0=xa010xa0%, postvoiding dribblingxa0=xa018.8xa0%). Thirty of 69 patients (43xa0%) had strictures ≥8xa0cm, and 39 (57xa0%) had strictures <8xa0cm—success rate was equal for both subgroups (87xa0%). Mean blood loss, mean operative time, and incidence of postvoid dribbling were significantly lower in strictures <8xa0cm.nConclusionBMG and PSG have comparable success rates in treatment of long anterior urethral strictures. Operative time is significantly longer in BMG. Long-segment strictures are associated with longer operative time, more blood loss, and more occurrence of postvoid dribbling. However, the length of the stricture has no influence on the success rate and functional outcomes of DOU.

Electroanatomical Mapping of the Urinary Bladder

A noncontact mapping system (EnSite) was used for electroanatomical mapping of the bladder simultaneously with pressure flow study in three women with lower urinary tract symptoms. We selected the periods of obvious detrusor activity. Data were processed to remove baseline drift, and an envelope of electrovesicography (EVG) data was created. The correlation coefficient for the correlation between between the EVG envelope and the detrusor pressure (Pdet) was calculated. Bladder geometry was successfully created in all 3 patients. Simultaneous recording of EVG and pressure flow data was successful in 1 patient. Scatter plots were made of the highest correlation coefficient, showing a positive correlation between the Pdet and the envelope, and negative correlation between abdominal pressure (Pabd) and the envelope. Minimal electrical activity could be observed. Significant weak to moderate correlation coefficients were found for the correlations between Pdet and EVG and between Pabd and EVG.

Survival of the artificial urinary sphincter in a changing patient profile

PurposeTo examine the functional survival of the artificial urinary sphincter (AUS) AMS800 in a changing patient population. Because of increasing experience and dexterity of the operating team, we hypothesize that patients with known risk factors nowadays have a better survival of their prosthesis. However, due to a change to a more complex case mix, overall results appear to be worse.Materials and methodsAll men who underwent implantation of an AUS between 2001 and 2016 because of urethral sphincter deficiency were retrospectively analyzed. Patients were divided in groups based on date of surgery and number of patients: 2001–2009 (G1), 2010–2013 (G2), 2014–2016 (G3). Baseline characteristics and additional therapies prior to implantation were analyzed in all groups. Risk factors for failure only in G1 and G2. Revision or explantation of the AUS was used as endpoint. Kaplan–Meier analysis was used to calculate survival of the device.ResultsA total of 129 patients (mean age 72u2009±u20099xa0years) underwent 129 primary implants, and 11 secondary implants. Median follow-up was 5.74xa0years in G1, 3.26xa0years G2 and 1.54xa0years G3. Approximately 25% of the patients in G1 had received adjuvant therapy for prostate cancer and 14% underwent previous surgery for incontinence. In G2, 51 and 55% underwent adjuvant therapy for prostate cancer and previous surgery for incontinence, respectively, G3 was comparable. The overall 50% survival improved in patients with radiotherapy and previous incontinence surgery in G2 as compared to G1.ConclusionsDespite the more complex patient population, the survival of the AUS did not decrease. In some patient categories, the AUS functional survival is even still improving over the past few years.

Male Stress Incontinence

All health professionals are familiar with the problem of stress urinary incontinence in females. Female anatomy predisposes to incontinence of urine due to sphincter weakness and in particular in association with childbirth. Health professionals however are less likely to be aware of the problem of stress incontinence in males, which does not usually occur as a primary condition. Since a male is not subjected to childbirth, the pelvic floor does not become weak unless it is affected by specific medical conditions. Thus stress urinary incontinence is much less common in males and less likely to present. Men have a tendency to draw less attention to the problem of urinary incontinence. Although a cause of much distress, incontinence in males tends to often remain a hidden condition. Incontinence is a common condition worldwide and leads to much suffering and in addition significant cost to society.