George A. Barbalias

alpha-BLOCKERS FOR THE TREATMENT OF CHRONIC PROSTATITIS IN COMBINATION WITH ANTIBIOTICS

PURPOSE This study was undertaken to evaluate the immediate and long-term effects of the combination of alpha-blockers and antibiotics in the treatment of chronic prostatitis. MATERIALS AND METHODS The patients eligible for study were assigned to 3 groups: group 1--nonprostatodynia, abacterial prostatitis (134), group 2--prostatodynia (72) and group 3--chronic bacterial prostatitis (64). alpha-Blockers were administered to all patients of groups 1 and 2 with demonstrable high maximal urethral closure pressure and typical clinical complaints irrespective of the presence of inflammatory findings in expressed prostatic secretion. alpha-Blockers were given to 50% of patients with bacterial prostatitis. Antibiotics were administered to all patients with positive expressed prostatic secretion cultures, and in half of those with abacterial prostatitis and inflammatory expressed prostatic secretion. Mean followup was 22 months (range 6 months to 3 years). The sign 1-tailed test was used for statistical analysis of data. RESULTS The recurrence rate of bacterial prostatitis was significantly reduced by alpha-blockade (expressed prostatic secretion culture negative) and symptom relief was achieved for many months. For abacterial prostatitis statistical analysis revealed a lower symptom recurrence rate in patients receiving only alpha-blockers in comparison with those treated with a combination of alpha-blockers and antibiotics. CONCLUSIONS The use of alpha-blockers is justified, not only for prostatodynia, but also for abacterial and bacterial prostatitis. In the latter case alpha-blockade not only caused enhanced clinical improvement but also reduced the recurrences as defined by expressed prostatic secretion positive segmental cultures.

Detrusor-External Sphincter Dyssynergia in Men with Multiple Sclerosis: An Omjnous Urologic Condition

A total of 27 men with multiple sclerosis underwent urodynamic evaluation as part of a prospective study of voiding dysfunction. Of 18 patients with detrusor-external sphincter dyssynergia 9 suffered serious urologic complications, including repeated episodes of urosepsis, vesicoureteral reflux and urolithiasis. None of the 9 patients without dyssynergia suffered any urologic complications. Urologic complications were correlated highly to the presence of detrusor-external sphincter dyssynergia and the severity of multiple sclerosis but not to duration of multiple sclerosis, age of the patient or type of dyssynergia. Although no treatment was without complications it appears that either anticholinergics plus intermittent self-catheterization or condom catheter drainage is superior to an indwelling catheter for initial conservative treatment. External sphincterotomy or urinary diversion may be necessary if conservative therapy fails.

VESICAL DIVERTICULA: ETIOLOGY, DIAGNOSIS, TUMORIGENESIS, AND TREATMENT Analysis of 74 Cases

A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.

Prostatodynia: Clinical and Urodynamic Characteristics

Twenty patients with prostatodynia were studied urodynamically with synchronous video-pressure-flow studies and electromyography of the external urethral sphincter. The most striking finding was a significant increase in maximum urethral closure pressure compared to an age and sex-matched control group. Typically, peak and average urinary flow rates were decreased. Another prominent feature was incomplete funneling of the bladder neck during voiding with an accompanying urethral narrowing at the level of the external urethral sphincter. These findings are not consistent with a diagnosis of tension myalgia of the pelvic floor or detrusor-striated sphincter dyssynergia but suggest a primary abnormality involving the pelvic sympathetic nervous system. We believe that more advanced methods than those available currently are needed to elucidate fully the role of the autonomic nervous system, especially its sympathetic component, in the etiology of prostatodynia.

Metal Stents: A New Treatment of Malignant Ureteral Obstruction

PURPOSE We report our experience with the use of metallic self-expandable and balloon expandable stents for the treatment of malignant ureteral obstruction. MATERIALS AND METHODS We treated 12 consecutive patients with malignant ureteral obstruction, for a total of 14 ureters with stents placed. We placed metallic balloon expandable stents in 6 patients and self-expandable metallic stents in the remaining 6. Mean patient age was 65 years and mean followup was 9 months (range 8 to 16). RESULTS Of the ureters 11 were patent without any additional manipulations during followup of 8 to 16 months. Secondary interventions were needed in 3 cases because of obstructive urothelial hyperplastic reaction, tumor ingrowth and local recurrence of the primary cancer invading the upper end of the stent. Two patients died 2 and 10 months after placement of the stent. CONCLUSIONS Both types of metal stents have advantages and disadvantages that must be balanced against each other when choosing the ideal device for the treatment of obstruction. Implantation of a metal self-expanding or balloon expanding stent is safe and effective for the palliative treatment of malignant ureteral obstruction in late stage cancer patients.

Characteristics of Neural Injury After Abdominoperineal Resection

A total of 13 men underwent synchronous video/pressure/flow electromyography studies after abdominoperineal resection of the rectum. All patients had diminished pressure in the proximal urethra and an incompetent vesical neck suggestive of sympathetic denervation. Five patients (38 per cent) had cystometric evidence of parasympathetic denervation and 7 (54 per cent) had electromyographic evidence of pudendal denervation. These data suggest that denervation owing to surgical injury is an important cause of persistent symptoms after abdominoperineal resection of the rectum.

Externally coated ureteral metallic stents: an unfavorable clinical experience.

Abstract Objective: The purpose of the present study was to evaluate the use of externally coated stents in patients with malignant ureteral obstruction. Materials and Methods: We have prospectively evaluated 16 patients, 10 men and 6 women, with malignant ureteral obstruction treated successfully by placement of Passager metal stents (Boston Scientific, Natick, MA, USA) bypassing the stricture. Mean patient age was 65.6 years (range 62–78 years). Ureteral patency was confirmed 24 and 48 hours by injection of contrast material through the nephrostomy tube, and after patency confirmation the nephrostomy catheter was removed. Results: All stents were positioned successfully, and the postoperative course was uneventful. In 13 cases (81.2%) the prostheses finally migrated into the bladder hindering overall ureteral patency (mean time of migration: 1.5 months). Patency was achieved in the remaining ureters ( n =3), during the follow-up period (mean: 8 months, range 6–16 months), without any need for further intervention. Conclusion: The inappropriate anchorage and the increased ureteral peristalsis are the main causes of migration towards the bladder, thus, minimizing the usefulness of this stent for the treatment of ureteral strictures.

URETEROILEAL ANASTOMOTIC STRICTURES: AN INNOVATIVE APPROACH WITH METALLIC STENTS

PURPOSE We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion. MATERIALS AND METHODS We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months. RESULTS No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement. CONCLUSIONS We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.

Neurologic Implications of the Pathologically Open Bladder Neck

Normally the bladder neck remains closed except during voiding. We reviewed 550 consecutive patients who underwent synchronous video/flow/pressure/electromyography studies to identify whether neurologic factors are involved in the pathogenesis of an abnormally open bladder neck. A total of 33 patients who had not undergone prior bladder neck surgery had an open bladder neck at rest. The prevalence of neurologic lesions in patients with an open bladder neck was significantly greater than in those with a normal bladder neck. However, there was no correlation between any specific lesion and the incidence of an open bladder neck. Patients with myelodysplasia had an inordinately high incidence of open bladder neck. We conclude that abnormalities of bladder neck innervation may result in a pathologically open bladder neck.

INTERSTITIAL CYSTITIS: BLADDER TRAINING WITH INTRAVESICAL OXYBUTYNIN

PURPOSE We assess the efficacy of intravesical administration of oxybutynin chloride in patients with interstitial cystitis. MATERIALS AND METHODS The study included 36 women with a mean age of 45 years with a diagnosis of interstitial cystitis. Patients were treated with gradual intravesical instillation of saline oxybutynin solution (oxybutynin group) or gradual filling of simple saline (control group). Evaluation parameters consisted of symptom problem index, voids per day, volume per void, functional bladder capacity, volume at first sensation, cystometric bladder capacity and cystometric volume at first sensation. RESULTS Statistically significant improvement of all evaluated parameters was found in both groups. When comparing the outcomes statistically significant improvement of parameters favored the oxybutynin group. CONCLUSIONS Bladder training alone produces a satisfactory result by gradually expanding the bladder, and an additional statistically significant improvement is evident with intravesical oxybutynin.