Jorge L. Lockhart

Malignant Vesical Tumors Following Spinal Cord Injury

We present 11 male patients with spinal cord injury and neurogenic bladder disease in whom malignant vesical tumors developed. The incidence of these tumors in our spinal cord injury unit was 2.3 per cent. We investigated retrospectively the clinical, endoscopic and radiographic diagnoses, and analyzed the treatment. The most common presenting symptoms were recurrent urinary infections, hematuria and stone disease. Two patients presented with abdominal symptomatology (a large abdominopelvic mass and peritonitis). Endoscopic evaluation was nonspecific in 8 patients (72 per cent). Squamous cell carcinoma was present in 9 patients (81 per cent). One patient had pure transitional cell carcinoma, and 1 had mixed squamous and transitional cell cancer. Cytology was of no value in these patients. The presence of local invasion and bulky disease suggests that ultrasonography or computerized tomography of the abdomen and pelvis should be included during followup. Radical cystoprostatectomy with pelvic lymphadenectomy is the recommended therapy for localized disease. The presence of active or recurrent urethral disease in 55 per cent of the patients indicated that urethrectomy also should be performed.

Polytetrafluoroethylene Injection for Urinary Incontinence in Children

We have treated 11 children for urinary incontinence with one or more endoscopic injections of polytetrafluoroethylene (Teflon) into the external urethral sphincter region. The procedure is simple to perform and without significant complications. Long-term results have been gratifying, with cure or improvement in 8 of the 11 patients.

Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma

Once again, there have been a significant number of papers on prostate cancer submitted and accepted, and this is reflected in that six of the nine papers published in this section this month relate to this disease. Many aspects of the condition are discussed. Readers may be interested learn of the severe complications associated with brachytherapy which the authors from Miami have described, and how they dealt with them. This type of therapy will continue to be reported in this journal, with several comments appearing in subsequent editions.

Continent colonic urinary reservoir (Florida pouch): Long-term surgical complications (greater than 11 years)

PURPOSE We analyzed the long-term results (greater than 10 years) of a continent cutaneous colonic urinary reservoir (Florida pouch), focusing primarily on the incidence of significant complications. MATERIALS AND METHODS Between January 1986 and October 1991, 179 patients underwent continent cutaneous colonic urinary reservoir construction. Of these patients 105 died of primary disease or were lost to followup, leaving 38 males and 36 females with a mean followup of 133 months with adequate data for analysis who are the subject of this report. The surgical technique has been previously reported. Briefly, a detubularized right colonic segment forms the reservoir, a tapered external limb reinforced at the ileocecal valve level allows continent catheterization and the ureters are directly anastomosed to the pouch. The diseases that prompted urinary diversion included bladder cancer in 28 cases, conversion from another diversion in 12, neurogenic bladder in 11, interstitial cystitis in 10, crippling incontinence in 4, radiation cystitis in 6, hemorrhagic cystitis in 1, exstrophy in 1 and colon cancer in 1. A total of 146 direct ureterocolonic reimplantations were performed. RESULTS Complications were grouped by etiology and the number of patients, including abdominal wall (peristomal hernia in 3 patients or 4%), external limb (incontinence in 5 or 6.7%, stomal stenosis in 3 or 4% and difficult catheterization in 1 or 1.4%), reservoir stones (4 or 5.4%), ureteral obstruction (primary reimplantation in 7 of 108 or 6.3%, repeat reimplantation in 4 of 24 or 16.4% and radiated ureters in 4 of 14 or 28.4%) and metabolic (persistent diarrhea in 2 or 2.7%, renal failure in 2 or 2.7% and low vitamin B12 in 3 or 4%). Severe acidosis developed in 4 individuals (5.5%). Of the 12 patients who underwent conversion from another type of diversion 7 (58%) experienced metabolic alterations. CONCLUSIONS In the long term continent colonic reservoirs have an acceptable complication rate. The most common problem is ureteral obstruction, especially in patients who have previously undergone irradiation (28.4% versus 6.3%, Fishers test p = 0.02). Patients in whom longer bowel segments were resected, such as those with conversion from another type of diversions, experienced a greater number of complications, especially ureteral obstruction associated with repeat reimplantation (16.4% versus 6.3%, Fishers test p = 0.23) and metabolic derangements (58% versus 6.4%, Fishers test p = 0.0001).

The Evaluation of Bladder Neck Dysfunction

Bladder neck dysfunction has been evaluated in 16 male patients. The efficacy of the traditional investigative methods for this entity is questionable and the value of video-urodynamics for definitive diagnosis is presented. The ability of the condition to masquerade as prostatis is apparent and treatment by unilateral bladder neck incision is proposed.

A continent colonic urinary reservoir : the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.

Remodeled Right Colon: An Alternative Urinary Reservoir

A total of 11 patients underwent bladder substitution or continent supravesical diversion with a remodeled right colonic segment as a urinary reservoir. Of the patients 1 woman and 2 men had bladder substitution: in 2 the bladder neck and urethra were preserved, and in 1 man radical cystoprostatectomy with preservation of the distal sphincteric mechanism was performed. All 3 patients currently are continent. In the 8 diversion patients an anti-incontinence mechanism was reconstructed with a segment of plicated ileum sutured to the abdominal wall. Six patients are completely dry between catheterizations every 4 to 6 hours, 1 man requires more frequent catheterizations, and the woman has refused self-catheterization and wears an external appliance. There were 18 ureterointestinal reimplantations performed successfully for upper tract protection, and 1 ureterocolonic reimplantation became partially obstructed and required percutaneous dilation. Reflux did not occur. This remodeled right colonic segment, reconstructed with interruption of the intestinal circular fibers, allows for storage of large urine volumes at reasonable pressures and it is a suitable alternative bladder substitution procedure. Plicated ileum has allowed for easy catheterization and it has been an adequate anti-incontinence mechanism when associated with this colonic reservoir.

Female Urinary Incontinence: Preoperatiye Selection, Surgical Complications and Results

A total of 98 women with stress urinary incontinence underwent surgical repair via 3 different techniques: 38 patients underwent a Burch colposuspension (group 1), 25 underwent a Stamey procedure (group 2) and 35 had a modified Pereyra operation (group 3). The main indication for an operation was clinically unacceptable incontinence, and urodynamic studies were done on all patients with associated stress and urge incontinence or who underwent reoperation. Subtracted bladder pressure recording was an important preoperative screening tool, since patients with high pressure instability did worse surgically than those with a stable bladder or low pressure instability. In patients with detrusor stability similar results were achieved for initial surgery and reoperations. Among the patients with a stable bladder with and without a previous anti-incontinence operation the over-all results were better in groups 1 and 3 than in group 2. Complications were of lesser magnitude in groups 2 and 3 than in group 1.

Morbidity associated with nonemergent hysterectomy for placenta accreta

OBJECTIVE The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

Ureteropelvic Junction Obstruction Resulting from Percutaneous Cyst Puncture and Intracystic Isophendylate Injection: An Unusual Complication

AbstractA case is reported of an iatrogenic ureteropelvic junction obstruction caused by percutaneous renal cyst decompression and an attempt at sclerosis with the intracystic sclerosing agent isophendylate.