Jacob Golomb

The Anatomy of Stress Incontinence: Magnetic Resonance Imaging of the Female Bladder Neck and Urethra

Clinical, urodynamic, radiological and endoscopic evaluations as well as operative results on more than 800 cases of stress incontinence treated at our medical center have led to a better understanding of the pathophysiology of female stress incontinence. We attempt to correlate these physiological concepts with information obtained from magnetic resonance images of the paraurethral and bladder neck areas in patients with known stress incontinence and normal controls. All magnetic resonance images were compared to cadaver step sections of the female pelvis. Normal controls without stress incontinence were used to define normal anatomy by magnetic resonance imaging. Etiology of incontinence was divided into either intrinsic urethral damage or anatomical malposition of an intact sphincteric unit. Our findings not only provide valuable support to basic concepts of the pathophysiology of stress incontinence but also help to establish normal findings of female paraurethral and bladder neck anatomy as seen by magnetic resonance imaging.

Four-Corner Bladder and Urethral Suspension for Moderate Cystocele

The classical approach to cystocele repair involves the approximation of lax pubocervical fascia through the anterior vaginal wall with narrowing of the bladder neck and proximal urethra by the Kelly-type plication. This procedure corrects the prolapse but when performed for the treatment of incontinence it has a high failure rate because the bladder neck and urethra are not placed into a high, supported, nonobstructed retropubic position. Furthermore, due to elevation of the bladder base without simultaneous elevation of the bladder neck and urethra, de novo stress urinary incontinence may occur. We developed a transvaginal needle suspension operation for the bladder and urethra that repairs anterior vaginal wall prolapse with excellent support of the bladder base and repositions the bladder neck in the high retropubic position, all during a simple and rapid operation that is tolerated well by the patient.

Variability and Circadian Changes in Home Uroflowmetry in Patients with Benign Prostatic Hyperplasia Compared to Normal Controls

We evaluated the variability and circadian changes in consecutive measurements of home uroflowmetry in 32 patients with symptomatic benign prostatic hyperplasia (BPH) and 16 healthy men. In the BPH group 476 uroflow measurements were recorded during 24 to 72 hours (mean 14.9 measurements per patient), and the controls produced 100 flow recordings (mean 6.25 measurements per participant). Great variability between consecutive peak flow rates was observed in the BPH group, ranging from at least 1 standard deviation in 28 of 32 patients (87.5%) to at least 2 standard deviations in 15 of 32 (47%). In 21 of 32 patients (65.6%) the highest recorded peak flow rate was greater than, while the lowest peak flow rate was less than the -2 standard deviations plot in voiding nomograms. In the control group variability between consecutive voiding episodes also was marked, namely at least 1 standard deviation in 8 of 16 men (50.0%) and at least 2 standard deviations in 2 of 16 (12.5%). However, in none of the control men was any peak flow rate measurement less than the -2 standard deviations line. Circadian changes in diurnal and nocturnal measurements of voided volume, interval to maximal flow, flow time, peak flow rate and adjusted peak flow rate were recorded in the BPH group, providing a urodynamic support to a well known clinical observation.

Bladder Neoplasms Associated with Augmentation Cystoplasty: Report of 2 Cases and Literature Review

Bladder neoplasms associated with augmentation cystoplasty have been reported to date in 12 patients. We add 2 cases: 1 with invasive transitional cell carcinoma involving the native bladder and bowel segment, and 1 with a poorly differentiated invasive oat cell (small cell) carcinoma confined to the bladder. The predisposing factors and pertinent literature are reviewed.

Complications of bladder substitution and continent urinary diversion

We, therefore, elected to review the specific complications as related to each type of the most common operative techniques, followed by general clinical considerations

Tapered intraluminal versus imbricated extraluminal valve: comparison of two continence mechanisms for urinary diversion.

One of the major limitations of continent intestinal reservoirs currently in use is failure of the efferent continence mechanisms. Unsatisfactory results have been reported in the literature in up to 40% of cases. While progress has been made toward better continence in urinary diversions, evolution of the actual continence mechanisms has been along two rather distinct paths: those with a valve mechanism placed inside the pouch (either by intussusception or surgical insertion), and those with the valve outside to the pouch (by imbrication of an externally located ileal segment). A canine experimental model was used to investigate a type of intraluminal continence mechanism and to compare it to an extraluminal imbricated ileocecal valve. In eight mongrel dogs a reservoir was made out of ascending and transverse colon with two different valve mechanisms--one intraluminal and one extraluminal--connected via separate stomas to the skin. Radiographic, sonographic, endoscopic and urodynamic studies of the pouch and its outlets were performed. Results showed that, in contrast to the extraluminal valve, continence in the intraluminal valve was volume dependent. The valve closing pressure of the intraluminal continence mechanism increased far beyond the values of the extraluminal valve (50.38 vs. 30.12 cm. H2O) at maximum pouch filling. Leakage of the intraluminal valve was observed at significantly higher pouch volumes than in the extraluminal valve (348 cc vs. 215 cc). In view of these results, the volume dependent intraluminal valve mechanism appears superior to an extraluminal type, especially at higher pouch volumes.

Kidney stone formed around refluxedsurgical staple and removed by transureteral endoscopic manipulation

We present a case of a kidney stone that developed around a surgical staple which refluxed up to the kidney following a Bricker urinary diversion and bilateral ureteroileal anastomosis. A GIA stapler had been utilized to construct the ileal conduit. The stone was retrieved by means of flexible ureterorenoscopy through the ileal conduit. To our knowledge, this is the first report of such a complication following construction of an ileal conduit with a stapling device.

Bilateral Ureteral Triplication with Crossed Ectopic Fused Kidneys Associated with the Vacterl Syndrome

We report a case of bilateral ureteral triplication associated with crossed ectopic fused kidneys, vesicoureteral reflux and the VACTERL syndrome (Vertebral defects, Anal atresia, Cardiovascular anomalies, Tracheo-Esophageal fistula, Radial and renal anomalies, and Limb defects). The relevant literature is reviewed.

Anatomy of urinary continence and neurogenic incontinence

The urinary bladder has a dual function – urine storage and periodic emptying. During storage the detrusor muscle is relaxed and the sphincteric mechanism is active to prevent urinary leakage while the bladder becomes progressively distended. In the voiding phase the pelvic floor and external urinary sphincter relax, the detrusor muscle contracts and bladder emptying ensues. The mechanism of these repetitive events depends on adequate detrusor muscle contraction and relaxation, competence of ureterovesical junctions and the urethral sphincter, as well as a complex central and peripheral neural control of both the smooth- and striated-muscle systems.

Basal cell hyperplasia of prostate: An elusive lesion?

We report a case of basal cell hyperplasia of the prostate accompanying benign prostatic hypertrophy. The histogenesis of the basal cells as well as the histologic features and differential diagnosis of basal cell hyperplasia are reviewed.