Gopal H. Badlani

Results of 212 Consecutive Endopyelotomies: An 8-‘Year Followup

Between 1983 and 1991 we performed 212 endopyelotomies on 110 cases of primary and 102 of secondary obstruction of the ureteropelvic junction. Of the 189 patients in the series 89% have been followed for a minimum of 6 months postoperatively, 63% for more than 3 years (3 to 8-year followup). Our overall success rate has been 86% with little difference being detected between the success that we have obtained with primary and secondary obstructions (85% versus 86%). Other variables, such as patient age, sex or side of obstruction, have little bearing on the outcome of the procedure. Endopyelotomy is passing the test of time as a safe and reliable means to correct ureteropelvic junction obstruction. Endopyelotomy should be the first choice for the correction of ureteropelvic junction obstruction in most patients.

Percutaneous surgery for ureteropelvic junction obstruction (endopyelotomy) : technique and early results

We incised ureteropelvic junction obstruction in 31 patients with a cold knife direct-vision urethrotome inserted through a percutaneous nephrostomy tract. In 12 patients renal calculi were removed endourologically during the same session. There were no immediate complications and nephrostograms showed adequate drainage in all cases. Of these patients 8 had previously undergone open pyeloplasty without success. The longest followup is almost 2 years. There have been 4 failures and, thus, the success rate is 87.1 per cent.

Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons.

PURPOSE With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.

Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent.

Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3–19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty‐two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality‐of‐life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12‐month pad weight test over 2.2 g. Quality‐of‐life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty‐six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12‐month visit. Neurourol. Urodynam. 20:157–165, 2001.

Endopyelotomy versus open pyeloplasty: comparison in 88 patients

We compared the results of the first 56 consecutive percutaneous corrections of ureteropelvic junction obstruction (endopyelotomy) at our institution with the most recent 32 consecutive cases of open pyeloplasty. The percutaneous procedure required less time (average 89.4 minutes versus 106.4 minutes for an open operation) and entailed less postoperative pain (60 per cent of the patients required an average of 4.7 unit doses of narcotics, whereas 88 per cent of the pyeloplasty patients required an average of 10.3 unit doses). The average hospital stay was less after endopyelotomy (average 6.2 versus 10.0 days) and return to normal activity occurred more quickly (average 19.8 versus 41.5 days). Endopyelotomy was successful in 87.5 per cent of the patients, with all failures being apparent within 6 weeks and they were easily correctable by traditional methods. Reported success rates of pyeloplasty ranged from 95 to 98 per cent.

Acute cerebrovascular accident and lower urinary tract dysfunction : A prospective correlation of the site of brain injury with urodynamic findings

PURPOSE We evaluated the effects of an acute cerebrovascular accident on the lower urinary tract and correlated the site of cerebrovascular accident with findings on urodynamic study. MATERIALS AND METHODS A total of 45 men and 15 women underwent a complete urodynamic study with electromyography within 72 hours of a cerebrovascular accident. Patients were divided into 5 different groups based on urodynamic findings. RESULTS The majority of cortical and internal capsule lesions resulted in detrusor hyperreflexia. A total of 28 patients (47%) had urinary retention, mainly due to detrusor areflexia (75%). Of 20 patients with hemorrhagic infarcts 17 (85%) had areflexia, compared to only 4 of 40 (10%) with ischemic infarcts. All 6 patients with cerebellar infarction had detrusor areflexia. CONCLUSIONS Our results confirm many previously reported findings. In addition, there was a specific correlation of cerebellar and hemorrhagic infarctions with detrusor areflexia.

Urolume endourethral prosthesis for the treatment of urethral stricture disease: Long-term results of the North American multicenter urolume trial

OBJECTIVES To evaluate the long-term results of the UroLume endourethral prosthesis for the treatment of recurrent bulbar urethral strictures. METHODS In a multicenter, prospective study 175 patients with recurrent bulbar urethral strictures were enrolled in a Food and Drug Administration (FDA) trial of the UroLume endourethral prosthesis. One hundred thirty-nine patients were available for follow-up at 1 year, and 81 patients were available for follow-up at 2 years. RESULTS Clinically and statistically significant results were seen at 1 year and sustained at 2 years. Re-treatment rate was down from 75.2% preinsertion to 14.3% 1 year postinsertion of the prosthesis. Explantation was required in only 3% of patients. CONCLUSIONS Based on these and European data, the UroLume endourethral prosthesis offers a significant advantage over the currently available treatments for recurrent bulbar urethral strictures.

VOIDING AND SEXUAL DYSFUNCTION AFTER CEREBROVASCULAR ACCIDENTS

PURPOSE We provide an up-to-date review of the urological manifestations of cerebrovascular accidents and their management, including sexual manifestations. MATERIALS AND METHODS We performed a comprehensive MEDLINE search for peer reviewed articles using key words and incorporated these data with our experience with the treatment of patients in an acute stroke unit, rehabilitation unit and ambulatory care center. RESULTS The knowledge of urological dysfunction after stroke is based largely on the evaluation of symptomatic patients. The predominant symptoms are urinary frequency, urgency and urge incontinence. Time after stroke has a significant influence on urological findings. Detrusor hyperreflexia is the most common urodynamic finding. Whereas the site and size of the stroke clearly have an influence on urological findings, to our knowledge the effect of the involved hemisphere is unclear. Urinary incontinence as an initial presentation in acute stroke is associated with a high mortality rate. Sexual dysfunction is common in men and women. Co-morbid conditions, such as diabetes mellitus, benign prostatic hyperplasia and urethral incontinence, may complicate evaluation and management. CONCLUSIONS A stroke has a profound effect on lower urinary tract function, sometimes resulting in significant morbidity. In well rehabilitated patients sexual dysfunction should be assessed and treatment may be considered to improve quality of life with safety. An overall conservative approach to management is recommended in the initial 3 to 6 months since improvement is common with time.

SPHINCTERIC INCONTINENCE : THE PRIMARY CAUSE OF POST-PROSTATECTOMY INCONTINENCE IN PATIENTS WITH PROSTATE CANCER

Post‐prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post‐prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostrate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty‐seven patients (69%) had VLPP less than 103 cm H2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post‐prostatectomy incontinence in patients with prostrate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence. Neurourol. Urodynam. 16:153–160, 1997.

Complications of Endopyelotomy: Analysis in Series of 64 Patients

We review the complications and failures in our first 64 patients who underwent endopyelotomy. There were 2 intraoperative complications (3.1 per cent) necessitating an open operation. Postoperative complications included leakage around the stent or irritative bladder symptoms, which were treated by repositioning the stent, and 2 instances of ureterovesical stenosis, which have led us to stent the entire ureter in recent cases. There were 7 failures, 4 in patients who in retrospect were not suitable candidates for the percutaneous operation (long stenotic segment and redundant renal pelvis) and 3 for which there was no obvious cause. All failures were apparent soon after removal of the stent that was inserted at the end of the procedure.