Ivan Gilja

A MODIFIED RAZ BLADDER NECK SUSPENSION OPERATION (TRANSVAGINAL BURCH)

A total of 36 female patients with genuine stress urinary incontinence underwent Raz needle suspension with fixation of suspension sutures to the iliopectineal ligament (transvaginal Burch procedure). By fixing suspension sutures to the iliopectineal ligament we expected to achieve a static suspension independent of everyday patient activities. Considering the small number of patients and limited followup, our results revealed continence in 80 to 85% of the patients after 3 years. We believe that fixation of suspension sutures to the iliopectineal ligament can favorably influence long-term results of needle suspension in the treatment of female stress urinary incontinence.

Conservative Treatment of Female Stress Incontinence with Imipramine

The results of a clinical study of conservative treatment of women with stress incontinence are presented. A daily dose of 75 mg. imipramine hydrochloride was given for 4 weeks. Special attention was paid to the effects of imipramine on the functional urethral length and maximum urethral closure pressure. A total of 21 women (71 per cent) stated that they were continent after treatment with imipramine, while 9 (29 per cent) did not improve and treatment was stopped. According to our results, imipramine extended the functional urethral length and made it independent of stress factors in women who were continent after treatment with imipramine. In patients with persistent incontinence the functional urethral length was extended significantly but was shortened with stress despite imipramine therapy. We believe that imipramine could be an alternative treatment in selected cases with stress incontinence.

Retrograde ejaculation and loss of emission : possibilities of conservative treatment

Twenty-five patients with retrograde ejaculation/loss of emission were treated with ephedrine sulfate or imipramine hydrochloride. Seventeen of them suffering from both diabetes and retrograde ejaculation were treated with ephedrine or, in case that ephedrine failed to convert retrograde ejaculation into anterograde ejaculation, with imipramine. Positive results were obtained in 5/17 (29.3%) patients, i.e. in 3 (17.6%) and 2 (11.7%) patients on ephedrine and imipramine, respectively. The daily dose of ephedrine was 50 mg and that of imipramine 75 mg, during a 4-week period. In the group with retroperitoneal lymphadenectomy, after treatment with ephedrine, only 1 (12.5%) had retrograde ejaculation while the remaining patients (n = 7) continued to lack semen emission. These 7 patients were treated with imipramine, and 3 of them (42.8%) achieved anterograde ejaculation. In one third of patients with retroperitoneal lymphadenectomy and diabetes, with retrograde ejaculation or loss of semen emission, conservative treatment can offer improvement or conversion to anterograde ejaculation.

Symptomatic Physiologic Hydronephrosis in Pregnancy

Objective: We present the incidence and results of treatment of symptomatic physiologic hydronephrosis in 3,400 pregnant women. Methods: We analyzed 103 consecutive women who presented with clinical signs and symptoms related to the upper urinary system. Renal sonography, urinalysis, serum creatinine levels, white blood cell (WBC) count, and urine culture were done in all patients at first visit and repeated at least once a month until 1 month after delivery. In patients who manifested acute pyelonephritis, urinalysis, WBC count, erythrocyte sedimentation rate and C–reactive protein levels were repeated every 3 days until normalization, and urine culture as well as renal sonography were performed once a week until 1 month after delivery. Conservative measures (positioning, analgesia, antibiotics) were performed in all patients with symptomatic physiologic hydronephrosis. If the patient’s condition was refractory to medical management, drainage of the ureter with a double pigtail stent was performed. Results: Conservative measures were successful in 97 (94%) of 103 patients but 6 (6%) patients had ongoing signs and symptoms of acute pyelonephritis progressing to urosepsis. In all of them, antibiotics were continued and a double pigtail stent was placed resulting in fast regression of symptoms, curing of renal infection and progresse of the pregnancies to the term with vaginal delivery. Conclusions: Symptomatic hydronephrosis in pregnancy can be treated conservatively. If the patient’s condition is refractory to medical management, an internal drainage with double pigtail stent may be necessary.

BLADDER FUNCTION IN PATIENTS WITH LUMBAR INTERVERTEBRAL DISK PROTRUSION

PURPOSE We prospectively studied the effect of lumbar intervertebral disk protrusion on bladder function. Cystometry findings were particularly examined according to spinal level of disk protrusion and urological symptoms. MATERIALS AND METHODS We evaluated 77 men and 37 women 25 to 63 years old with lumbar intervertebral disk protrusion. Urodynamic investigation included uroflowmetry and simultaneous recording of intravesical, abdominal and detrusor pressure during bladder filling and voiding. RESULTS Detrusor areflexia was noted in 31 of the 114 patients (27.2%), while detrusor activity was normal in the remaining 83. According to the spinal level of disk protrusion, detrusor areflexia was evident in 3 of the 8 cases of L3, 10 of the 54 L4 and 18 of the 52 L5 disk protrusion. All 31 patients with detrusor areflexia reported difficult voiding with straining. CONCLUSIONS Detrusor areflexia develops in approximately a quarter of the patients with lumbar intervertebral disk protrusion. We did not find that the spinal level of lumbar disk protrusion had an effect on detrusor activity. All patients with detrusor areflexia had voiding disorders that manifested as voiding with straining.

Comparative Analysis of Bladder Neck Suspension Using Raz, Burch and Transvaginal Burch Procedures

Purpose: Ever since Pereyra described needle suspension of the bladder neck for the treatment of stress urinary incontinence in women, numerous modifications have been presented. There were variations in the success reported by different authors. We report 3-year follow-up results in 146 women operated on for stress urinary incontinence using Raz, Burch and our own new procedures. Materials and Methods: During a 5-year period, 146 women were operated on for genuine stress urinary incontinence. Using the method of Raz, and transvaginal Burch as well as the Burch retropubic urethropexy, a modified bladder neck suspension was performed in 46 (32%), 44 (30%) and 56 (38%) patients, respectively. In all patients a prior gynecological or urological operation for urinary incontinence and a clear neuropathic condition had been excluded before surgery. The routine diagnostic procedure consisted of multichannel cystometry, voiding cystourethrography, infusion urography and cystoscopy. A pressure-flow electromyography study was done in patients with a residual volume greater than 50 ml following voiding. The operations were performed by the same surgeon (I.G.). Initial follow-up was done after 12 months and then every year. Results: Urodynamic testing did not reveal significant differences between Burch and Raz (p = 0.2652), Raz and transvaginal Burch (p = 0.5745) as well as between Burch and transvaginal Burch procedures (p = 0.7602; Fisher’s exact test). Three years after surgery, 50 of 56 (89.3%; Burch procedure), 37 of 46 (80.4%; Raz modification) and 38 of 44 patients (86.4%; transvaginal Burch) were continent. Conclusions: There is no reason (except patient condition) to prefer any of the numerous modifications of bladder neck suspension. We believe that the success of the operation lies in adequate mobilization of the bladder neck and urethra as well as in a surgeon’s familiarity with the procedure.

Tansvaginal Needle Suspension Operation: The Way We Do It

Objectives: To evaluate the long–term results of the transvaginal needle suspension operation for urinary stress incontinence. Materials and Methods: A total of 88 women with proved genuine stress incontinence were treated with transvaginal needle suspension with fixation of suspension sutures to the rectus fascia using the technique of crossing suspension sutures. By using this method the proximal end of suspension suture from one side is tied with the distal end of suspension suture from the other side. The suspension sutures fixed in this way ensure 3–4 cm of rectus fascia which is used as a carrier of the suspension sutures. The same urologist peformed 88 consecutive operations. Clinical and urodynamic evaluations were performed at 6 months, 1 year and 5 years after surgery with the same technique and the same equipment. Results: Analysis of the questionnaire showed that 81 patients (92.0%) were continent after 6 months while 78 (88.6%) patients were still continent after 1 year. After 5 years (n = 71) there were only continent 54 (76.0%) and incontinent patients (n = 17, 23.9%). Urodynamic analysis showed that 49 (69.0%) patients were continent after 5 years (n= 71). The increase in the number of incontinent patients is achieved at the cost of the previously continent patients. Of the 22 incontinent patients (after 5 years), 16 were still stress incontinent, while 6 (8.3%) patients had urge incontinence due to de novo detrusor instability. Three patients (n = 88, 3.4%) had undergone unilateral suture removal due to infection without influence on their continence status. In 2 patients (n = 88, 2.2%) the clinical pictures were highly suggestive of ilioinguinal nerve entrapment. Conclusions: Our results suggest that the transvaginal needle suspension operation is satisfactory for the management of genuine stress incontinence in women. However, we believe that the success of any suspension operation lies in adequate mobilization of the bladder neck and urethra (anterior vaginal wall) as well as in a surgeon’s familiarity with the procedure.

Is testis sparing surgery an acceptable option for small testicular malignant tumor with normal contralateral testicle

Bojanic et al described an interesting approach to treatment of small testicular tumor (<2 cm) in cases where the contralateral testicle is normal. Particularly intriguing is the treatment of nine patients with malignant tumor who underwent testis sparing surgery (TSS) with active surveillance. Over a mean follow-up of 40.9 ± 20.5 months (range 5-65), one of the nine patients developed a local recurrence. The authors concluded that TSS could be offered safely in highly selected patients with germ cell tumors. Today, TSS is accepted as an option in metachronous and synchronous bilateral tumors or in a tumor in a solitary testis with normal preoperative testosterone levels, with the tumor volume less than 30% of the testicular volume. TSS is not indicated in the presence of normal contralateral testicle, except in special cases with all the necessary precautions. A question arising here is:What are those special cases where TSS is indicated, and the contralateral testicle is normal? Multiple biopsies of the operated testicle are listed as one of the mandatory procedures with the testis sparing technique. In the presence of testicular intraepithelial neoplasia (TIN), an adjuvant local radiotherapy is recommended. The reason for such an approach is the fact that TIN is confirmed in biopsy in 82% of patients, and some studies report even higher percentages. An important fact is that the spontaneous course of TIN gives an estimated risk of developing invasive growth in a testis harboring TIN of 50% within 5 years and 70% within 7 years. It is assumed that all patients harboring TIN will develop an invasive tumorwith time, although seldom cases of “burned out” TIN have been reported. Considering the above facts, an active surveillance does not seem the best option for these patients, especially with the normal contralateral testicle. A drawback of the study by Bojanic et al is the lack of information on testicular biopsy performed, and consequently on the presence of TIN. The current understanding is that radical orchiectomy is the method of choice even for small testicular malignant tumor with the normal contralateral testicle, especially when associatedwith TIN. If an organ sparing surgery is performed, and the presence of TIN is confirmed in biopsy, an adjuvant radiotherapy of the testicle is recommended. Do we have the answer to the question on what these “special cases” are that would be candidates for TSS with active surveillance, andwith the normal contralateral testicle? In certain cases, these could be patients with small testicular malignant tumor not associated with TIN.

Re: J. Alfred Witjes, Thierry Lebret, Eva M. Compérat, et al. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol 2017;71:462–75

We have been following with great interest the evolution of the European Association of Urology (EAU) guidelines for the treatment of muscle-invasive carcinoma of the urinary bladder. Since our department performs more than 100 cystectomies per year, of which >50% involve orthotopic neobladders, we find the indications and contraindications for orthotopic urinary diversion of particular interest. The 2015 EAU guidelines made an important step forwards. They point to the fact that an orthotopic neobladder could be considered in patients with N1 involvement but not in those with N2 or N3 involvement. The recently published 2016 guidelines (Section 10.4 Diversion) state that an orthotopic neobladder can also be considered in patients with positive lymph nodes [1]. Obviously, the limits have shifted, so N2 and N3 tumours are no longer contraindications for orthotopic diversion. A common factor arising from all the papers in favour of such a development is resectable disease. A similar situation occurs with local extent of disease (T stage). A growing number of authors consider that a locally advanced stage (stages T3–T4a) but for resectable disease is not a contraindication for an orthotopic neobladder. The prevalent opinion is that even a local recurrence, observed in 10–12% of patients, rarely affects the normal neobladder function for the rest of the patient’s life [2–4]. In line with those findings, the authors of the International Consultation on Urological Diseases (ICUD)–EAU international consultation on bladder cancer [5] concluded that locally advanced disease has little impact on decisions on the suitability of orthotopic diversion.