Frederick A. Klein

Incidence and Predictors of Complications With Sacral Neuromodulation

OBJECTIVESnTo determine the incidence and predictors of complications with sacral nerve stimulation (SNS).nnnMETHODSnA prospective, longitudinal analysis of all patients treated with SNS was performed to define the incidence of complications and identify the predictors of these adverse events (AEs). All patients underwent staged SNS placement with the InterStim device for treatment of refractory voiding dysfunction. The patients were followed up for evidence of AEs and device efficacy. The patient and device variables were examined statistically for evidence of predictive value.nnnRESULTSnFrom September 2001 to March 2008, 221 patients with a mean age of 48.8 years underwent SNS lead placement for the treatment of intractable urinary urgency/frequency (n = 121), urge incontinence (n = 63), or urinary retention (n = 37). Of this group, 202 patients (91.4%) experienced a >50% improvement in symptoms and underwent implantable pulse generator placement. At a mean follow-up of 36.9 months, 67 patients (30.3%) had experienced AEs (pain in 6, elective removal in 10, lack of efficacy in 11, trauma in 18, infection in 7, hematoma in 3, and lead migration in 12) requiring 44 lead revisions and 47 implantable pulse generator revisions. The significant predictors of AEs included a history of trauma (P < .001), a change in body mass index class (P < .001), enrollment in a pain clinic (P = .008), the duration of follow-up (P = .002), and a history of AEs (P < .001).nnnCONCLUSIONSnThe results of our study have shown that SNS is an effective treatment for patients with intractable voiding dysfunction. Complications are not uncommon but can be minimized with better patient selection.

Short-Term Efficacy of Botulinum Toxin A for Refractory Overactive Bladder in the Elderly Population

PURPOSEnWe determined the efficacy of intravesical botulinum toxin A injection for refractory overactive bladder in elderly patients.nnnMATERIALS AND METHODSnPatients 75 years or older with refractory urinary urgency were prospectively evaluated and offered treatment of symptoms with botulinum toxin A. A voiding log was obtained and urodynamics were performed before treatment. Patients underwent injection of 200 U botulinum toxin A (Botox(R)) into the detrusor muscle at 20 sites under cystoscopic guidance. Patients were followed postoperatively for evidence and duration of success, and treatment related complications.nnnRESULTSnFrom January 2006 to June 2007, 18 females and 3 males with a mean age of 81.2 years (range 75 to 92) in whom detrusor overactivity was confirmed on urodynamics and who were refractory to or intolerant of antimuscarinics were treated with intravesical botulinum toxin A. Preoperatively the mean +/- SD number of daily voids was 11.4 +/- 1.67 and the mean number of pads per day was 4.0 +/- 0.89. One month after treatment 16 of the 21 patients (76%) reported greater than 50% improvement in symptoms after 1 injection. Specifically there was a significant improvement in the mean number of voids per day (5.19 +/- 0.83, p <0.001) and in the number of pads used daily (1.3 +/- 0.60, p <0.001). Two of the remaining 5 patients demonstrated greater than 50% improvement following repeat injection, while 3 did not show improvement after 2 injections. Mean time to deterioration was 7.12 months. There were no treatment related complications.nnnCONCLUSIONSnIntravesical botulinum toxin A for detrusor overactivity in the elderly population appears to be efficacious and durable. Given its low incidence of adverse events, it should be considered a viable treatment option in this population.

Sacral Nerve Stimulation for Treatment of Refractory Urinary Retention: Long-Term Efficacy and Durability

OBJECTIVESnTo examine the long-term efficacy and durability of sacral nerve stimulation (SNS) for the treatment of refractory, nonobstructive urinary retention.nnnMETHODSnA retrospective study of all patients who underwent SNS with the InterStim device for refractory, nonobstructive urinary retention was performed. All patients had their history taken, underwent physical examination and urodynamic study, and completed a voiding diary before treatment with staged SNS. Patients with greater than 50% improvement in symptoms underwent implantable program device placement. Patients were followed up for evidence of postoperative complications, device failure, and treatment efficacy. Statistical analyses were performed.nnnRESULTSnFrom June 1, 2000 to February 1, 2007, 40 patients were treated with SNS for refractory, nonobstructive urinary retention. Of the 40 patients, 29 had complete urinary retention (using clean intermittent catheterization), and 11 demonstrated incomplete retention (elevated postvoid residual urine volume). Of the 40 patients, 28 (70%) demonstrated greater than 50% improvement in symptoms and underwent implantable program device placement. At a mean follow-up of 40.03 +/- 19.61 months, 24 (85.7%) of 28 patients demonstrated sustained improvement of greater than 50%. Of the 28 patients, 4 (14.3%) had their InterStim device removed and 6 (21.4%) required revision. Among those with complete retention, significant improvement occurred in the number of catheterizations/day and the volume/catheterization (P <0.001). Among those with incomplete retention, significant improvement occurred in the postvoid residual urine volume (P <0.001).nnnCONCLUSIONSnAt a mean follow-up of 40 months, 85.7% of patients with refractory, nonobstructive urinary retention demonstrated greater than 50% improvement in symptoms with SNS. For 911 patients, a statistically significant improvement in voiding parameters resulted.

Sacral Nerve Stimulation for Refractory Overactive Bladder in the Elderly Population

PURPOSEnWe determined the long-term outcome of sacral nerve stimulation for refractory overactive bladder in the elderly population.nnnMATERIALS AND METHODSnWe performed a prospective longitudinal study to better characterize the outcome of sacral nerve stimulation in female patients 70 years old or older with refractory overactive bladder. Demographic and perioperative data were recorded. Patients were followed postoperatively for evidence of successful stage conversion, device durability and efficacy, and postoperative complications. Patients were retrospectively compared to a cohort of female patients younger than 70 years with refractory overactive bladder. Statistical analysis was performed.nnnRESULTSnBetween July 2001 and February 2008, 19 elderly female patients with refractory overactive bladder underwent stage 1 lead placement. Of the patients 17 (90%) who reported greater than 50% improvement in symptoms based on a 1-week followup voiding log underwent implantable pulse generator placement. No intraoperative or immediate postoperative complications were noted. At a mean followup of 48.5 months 11 patients (65%) had a functional implantable pulse generator with greater than 50% objective improvement over baseline. Compared to matched patients younger than 70 years elderly patients had a similar conversion rate and adverse events but were significantly more likely to undergo device removal (p = 0.018).nnnCONCLUSIONSnBased on our experience elderly patients have a high conversion rate, few adverse events, and a high level of device efficacy and durability with sacral nerve stimulation. Although more mature multicenter data are needed, it appears that sacral nerve stimulation in geriatric patients is safe and efficacious, and should be judiciously offered to those with refractory voiding symptoms.

Primary female urethral carcinoma. A retrospective comparison of different treatment techniques

Between July 1951 and January 1984, 14 female patients (11 black and three white; average age, 58 years) were treated for primary urethral carcinoma. Five patients had radical surgery, six received preoperative radiotherapy (2000 cGy in five fractions) followed by anterior exenteration, and three had definitive radiotherapy (external beam 4000 to 5000 cGy plus 2800 to 3000 cGy interstitial implant). The mean follow‐up times were 5.6, 3.9, and 2 years, respectively. In the first two groups, two of 11 patients (18%) are alive and well with no evidence of disease. The rest died of local as well as distant disease. In the third group, two of three patients (67%) are alive and well with no evidence of disease. The third patient died of papillary adenocarcinoma of the uterus 30 months later with no evidence of the primary tumor.

Nephron Sparing Surgery Using a Bipolar Radio Frequency Resection Device

PURPOSEnWe evaluated operative outcomes during nephron sparing surgery using a handheld radio frequency ablation resection device.nnnMATERIALS AND METHODSnPatients with a newly diagnosed renal mass who elected treatment were prospectively enrolled in a comparative trial designed to evaluate the usefulness of the handheld HABIB 4X radio frequency ablation device during open nephron sparing surgery. Preoperative variables were determined and patients subsequently underwent open nephron sparing surgery with (group 1) or without (control group 2) the assistance of the radio frequency ablation device. Data were collected on preoperative and postoperative creatinine and hematocrit, estimated operative blood loss, intraoperative and postoperative complications, and pathological outcomes.nnnRESULTSnA total of 90 patients underwent open nephron sparing surgery with (45) and without (45) the radio frequency ablation device. Mean pathological tumor size was 3.31 and 3.13 cm in groups 1 and 2, respectively (p = 0.49). Mean estimated blood loss was 133.2 and 417.2 cc in groups 1 and 2, respectively (p <0.001). Mean operative time was 83.5 and 97.2 minutes in groups 1 and 2, respectively (p = 0.012). Ten of 45 group 2 patients underwent hilar clamping with hypothermia, while no patients in group 1 underwent hilar clamping. Margins were positive in 1 patient in group 1 (2.2%) and in 2 in group 2 (4.4%). Group 1 complications included postoperative urine leakage in 1 case, which required stent placement. Group 2 complications included 2 cases of urine leakage requiring stent placement, 4 of blood transfusion, 2 of ureteral lacerations, 2 episodes of clot retention and 1 death.nnnCONCLUSIONSnThe handheld radio frequency ablation device can yield a significant benefit during open nephron sparing surgery, namely decreased blood loss and operative time.

Penoscrotal mass: A rare presentation of herpes simplex virus infection

A 55-year-old man presents with a 10-cm condylomatous penoscrotal mass. Final pathology after surgical removal reveals a rare vegetative lesion with underlying herpes simplex virus infection. Along with neoplasia, infectious causes must remain in the differential diagnosis in the immunocompromised patient who presents with an atypical lesion.