John J. Smith

Intravaginal Stimulation Randomized Trial

PURPOSE The effectiveness of intravaginal electrical stimulation was compared to standard therapy in the treatment of genuine stress urinary incontinence and detrusor instability. MATERIALS AND METHODS A total of 57 women with urinary incontinence was evaluated with video urodynamics and voiding diaries before and after treatment. Of the women 18 with stress urinary incontinence were randomized to electrical stimulation or Kegel exercise and 38 with detrusor instability were randomized to anticholinergic therapy or electrical stimulation. RESULTS Of patients using electrical stimulation in the stress urinary incontinence group 66% improved and 72% of the patients with detrusor instability treated with electrical stimulation improved. These rates were not statistically significant when compared to traditional therapy. CONCLUSIONS Electrical stimulation is safe and at least as effective as properly performed Kegel and anticholinergic therapy in the treatment of stress urinary incontinence and detrusor instability.

Retroperitoneal Lymph Node Dissection in Malignant Mesothelioma of Tunica Vaginalis Testis

A case of metastatic mesothelioma of the tunica vaginalis testis in a 57-year-old man is reported. Clinicopathological findings and treatment options are reviewed.

Multimodality Treatment of Complex Renal Calculi

More than 2,500 patients were treated for urolithiasis from 1984 to 1987. In an effort to define the relative role of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy with respect to size, location and composition of the calculus 912 of these patients (224 of whom underwent percutaneous nephrolithotomy and 688 of whom underwent extracorporeal shock wave lithotripsy) were reviewed. Size proved to be the only significant factor in the success and complication rates of extracorporeal shock wave lithotripsy but it did not affect the outcome of percutaneous nephrolithotomy. The roles of these 2 modalities were then examined with respect to the treatment of complex renal calculi. We reviewed 376 patients with complex renal calculi, including 40 percutaneous nephrolithotomy patients from the initial 912 patients studied. The initial therapy in 100 of these patients, treated consecutively, was extracorporeal shock wave lithotripsy. The remaining 276 patients were treated by percutaneous nephrolithotomy. The success rate of extracorporeal shock wave lithotripsy monotherapy in the treatment of complex renal calculi was 36%. The success rate of primary percutaneous nephrolithotomy was 83%. We conclude that percutaneous nephrolithotomy should be the primary therapy for patients with complex renal calculi. Extracorporeal shock wave lithotripsy is the preferred treatment for patients with smaller calculi and as an adjunct to percutaneous nephrolithotomy.

Laparoscopic repair of ureterosciatic hernia.

Ureterosciatic herniation is a rare benign event that can mimic diverticulosis or irritable bowel syndrome. This entity has been managed by a number of open surgical techniques. Laparoscopic repair of this entity enabled us to identify the defect, interpose mesh, and obliterate the hernia defect with minimal morbidity. This represents the first report of laparoscopic repair of a ureterosciatic hernia.

Mixed incontinence: does preoperative urodynamic detrusor overactivity affect postoperative quality of life after pubovaginal sling?

OBJECTIVE Our purpose was to determine if women with mixed urinary incontinence (MUI) and urodynamic detrusor overactivity (DO) have less improvement in urinary symptoms after pubovaginal sling surgery (PVS), compared to MUI without DO. MATERIALS AND METHODS Women with preoperative MUI symptoms prior to PVS were identified through retrospective review. DO was defined as a symptomatic 5 cm H20 detrusor pressure or greater rise during urodynamics. MUI patients with and without DO before PVS were divided into Groups A and B, respectively. All patients had returned a completed Urogenital Distress Inventory 6 (UDI-6) questionnaire and a 3-day diary of pad usage before surgery and at each postoperative visit. Study endpoints included change in total UDI-6 score, and change in number of pad use/day after PVS. RESULTS 73 patients were identified, 31 in Group A and 42 in Group B. Mean follow-up after PVS was 15 and 16 months, respectively (p = 0.59). Preoperative total UDI-6 scores were 11.8 and 12.7 (p = 0.30) for Group A and B. Mean changes in total UDI-6 after PVS were - 8.0 and - 10.2 (p = 0.030), respectively. After PVS, both groups reported similar mean reduction in pad/day usage from preoperative baseline (-2.57 vs. --2.49, p = 0.83). There were no differences between the groups when comparing demographic, urodynamic, or operative data. CONCLUSION MUI patients had improved continence and quality of life after PVS. However, MUI patients with DO had less improvement in UDI-6 scores after PVS, despite a similar reduction to pad use/day.

Retropubic surgery for stress urinary incontinence

More than 150 surgical techniques have been proposed in the literature for treating stress urinary incontinence. Many of the original published approaches were vaginal, but through the years the literature has expanded to include needle suspension, pubovaginal slings, and retropubic procedures. In this chapter, we focus on retropubic approaches for the treatment of SUI and discuss the physiology, indications, technical details and the complications of these procedures.

ENDOSCOPIC INJECTION OF GLUTARALDEHYDE CROSS-LINKED COLLAGEN FOR EFFERENT LIMB INCOMPETENCE IN THE INDIANA RESERVOIR

PURPOSE We determined the clinical applicability, safety and efficacy of endoscopically injected glutaraldehyde cross-linked collagen for the treatment of efferent limb incompetence in the incontinent Indiana urinary reservoir. MATERIALS AND METHODS Six patients were diagnosed with incompetence of the efferent limb of the Indiana reservoir by video urodynamics. Glutaraldehyde cross-linked collagen was injected through the efferent limb at the level of the ileocecal valve. Outcome was assessed by evaluation of dryness and pouchograms. RESULTS With a mean followup time of 26 months (range 6 to 36) after the last injection 5 of the 6 patients were cured. The remaining patient, although improved, had a small capacity and subsequently underwent ileal patch augmentation. No patient failed to improve. The mean volume of collagen was 16 ml. (range, 5 to 26). Reservoir volume increased from 150 to 400 ml. CONCLUSIONS The use of glutaraldehyde cross-linked collagen in the treatment of the incontinent Indiana reservoir is safe and effective.

CONSERVATIVE SURGERY FOR URETERAL TUMOR ASSOCIATED WITH HORSESHOE KIDNEY

PURPOSE We demonstrate the successful conservative management of a ureteral tumor in a horseshoe kidney. MATERIALS AND METHODS A patient with low grade transitional cell carcinoma of the left lower ureter had asymptomatic horseshoe kidney. Biopsy specimen revealed low grade tumor in the lower urinary tract that was associated with a congenital abnormality. The patient underwent total ureterectomy with bladder cuff excision and ileal ureteral interposition. RESULTS With this technique renal function was preserved without resection through the isthmus of the kidney. The patient has no evidence of recurrent disease after 20-month followup by cytology, computerized tomography, excretory urogram and cystoscopy. CONCLUSIONS Organ preserving surgery is an alternative to total nephroureterectomy in lower ureteral tumors in select patients.

1077 EMPIRIC ANTIBIOTICS FOR AN ELEVATED PSA A RANDOMIZED, PROSPECTIVE MULTI-INSTITUTIONAL TRIAL

32 Background: The impact of an empiric course of antibiotics for a newly elevated PSA in an asymptomatic male is poorly understood. METHODS Men of any age with a PSA > 2.5 ng/ml and normal digital rectal examination undergoing their first prostate biopsy were recruited from six medical centers. Patients with previous biopsy, prostate cancer, urinary tract infection (UTI) or prostatitis within the prior year, antibiotic use within one month, 5-alpha reductase inhibitor use, allergy to fluoroquinolones or clinical suspicion of UTI were excluded. Men were randomized to two weeks of ciprofloxacin 500 mg twice daily or no antibiotic. A PSA was obtained 21-45 days following randomization and immediately prior to prostate biopsy. All patients received institution-specific prophylactic peri-procedural antibiotics. Primary endpoint was change in PSA between baseline and on the day of biopsy. The trial was closed early following an interim analysis and decision rule for futility and early stopping. RESULTS Complete data was available on 77 men with a mean age of 60.6 (IQR: 53.8 - 66.7). In the control group (no antibiotic; n=39), mean baseline and pre-biopsy PSA were 6.5 and 6.9 ng/ml, respectively (p=0.8). In men receiving antibiotic (n=38), mean baseline and pre-biopsy (post-antibiotic) PSA were 7.6 and 8.5 ng/ml, respectively (p=0.7). Prostate cancer was detected in 36 (47%) men. Detection rates did not significantly differ between individuals with an increasing PSA or decreasing PSA between the two measurements. CONCLUSIONS Empiric use of antibiotics for an elevated PSA in an asymptomatic patient is not of clinical benefit.

The Use of Human Dermal Allograft Material for Transvaginal Slings

We evaluated the safety and efficacy of using human dermal allograft material for transvaginal slings to treat female stress urinary incontinence (SUI). Materials and Methods We present a prospective series of 253 patients with SUI treated with a transvaginal sling using a Repliform cadaveric human dermal allograft (LifeCell Corp., The Woodlands, Texas) and a bone anchor fixation kit. Clinical history, urogynecologic examination and videourodynamics were performed preoperatively. Results were assessed by a third party through validated quality of life questionnaires (Incontinence Impact Questionnaire and Urogenital Distress Inventory), overall impression and percent of improvement as perceived by the patients, and pad use. Scheduled follow-up examination were performed to rule out erosion, infection, obstruction, pain or recurrent incontinence. Results Complete follow-up was available on 234 of 253 patients. Average follow-up was 18 months. Of the patients 78% were cured or improved according to the questionnaires. The average improvement was 80%. At 18 months of follow-up incontinence average distress and scores decreased 10 and 7 points, respectively. Complications were de novo urgency in 5% of cases, recurrent SUI in 15% with no cases of persistent SUI, retention in 2% and slow vaginal wall healing in 1.7%. Of 156 patients 51 (22%) had persistent urgency. There were no cases of vaginal or urethral erosion, osteitis pubis or osteomyelitis. Conclusions Our data indicate that use of human dermal allograft for transvaginal slings is associated with low complication rates and favorable outcomes at an average of 18 months of follow-up.