Joseph Abarbanel

Changing Trends in the Management of Iatrogenic Ureteral Injuries

PURPOSE We evaluated changing trends in the management of late diagnosed iatrogenic ureteral injuries before and after the introduction of percutaneous nephrostomy. MATERIALS AND METHODS The study included 44 patients of whom 24 were treated primarily by immediate reconstructive surgery from 1979 to 1984 and 20 were treated primarily by percutaneous nephrostomy tube insertion beginning in 1985. RESULTS Six of the 24 patients underwent ureteroneocystostomy and 18 underwent end-to-end uretero-ureteral anastomosis to repair the injury. Postoperatively 18 patients had a urinary tract infection. Hospital stay after reconstructive surgery ranged from 14 to 35 days (average 18). Long-term followup showed a normal upper urinary tract in 22 patients and mild to moderate hydroureteronephrosis in 2. Of the 20 patients who underwent percutaneous nephrostomy 16 (80%) had complete spontaneous recovery of the injured ureter after 14 to 66 days (average 32). Hospital stay after the insertion of the percutaneous nephrostomy tube ranged from 3 to 5 days. Urinary tract infection developed in 4 patients and mild hydronephrosis was noted in 1 on long-term followup. CONCLUSIONS The primary management of ureteral injury by percutaneous nephrostomy resulted in significantly decreased reoperation and morbidity rates, and enabled spontaneous recovery of the injured ureter in the majority of patients.

TRANSVESICAL PROSTATECTOMY IN ELDERLY PATIENTS

PURPOSE We assessed the results of transvesical prostatectomy in patients older than 80 years. MATERIALS AND METHODS We studied 98 patients 80 to 90 years old who underwent transvesical prostatectomy between 1986 and 1993, including those with a large prostate (preoperative estimated weight more than 80 gm.), numerous or large cystolithiasis and large bladder diverticulum, which are indications for open prostatectomy. Clinical data were obtained by chart review. RESULTS The indications for surgery were urinary retention in 53 patients (54%), severe obstructive urinary symptoms in 18 (18.4%), cystolithiasis in 17 (17.3%), prostatic bleeding in 10 (10.2%) and bladder diverticulum in 2 (2%). Accompanying diseases were present in 69 patients (70.6%), including ischemic heart disease in 41 (42%), diabetes mellitus in 17 (17.3%) and arterial hypertension in 14 (14.3%). A total of 59 patients (60.2%) underwent surgery while under general anesthesia and 39 (39.8%) received regional anesthesia. Average operative time was 62 minutes. Of the patients 40 (40.8%) received 1, 14 (14.3%) received 2 and 2 (2%) received 4 units of blood. No postoperative deaths or life threatening complications were noted. The immediate postoperative complications included urinary tract infection in 20 patients (20.5%), wound infection in 3 (3.0%) and orchiepididymitis in 3 (3.0%). Postoperative mild to moderate incontinence was noted in 2 patients (2.0%). Bladder neck constriction and urethral strictures occurred in 4 (4.1%) and 3 (3.0%) patients, respectively. CONCLUSIONS Transvesical prostatectomy can be performed safely in elderly patients with a low morbidity rate.

Combined Retropubic Prostatectomy and Preperitoneal Inguinal Herniorrhaphy

Inguinal hernia and an enlarged prostate causing urinary obstruction are 2 disorders with a higher frequency among elderly patients. The anatomical proximity of an inguinal hernia to the enlarged prostate raises the possibility of joint, concurrent surgical treatment of both disorders. We report on the successful preperitoneal repair via a Pfannenstiel incision of 131 inguinal hernias in 97 patients who had undergone retropubic prostatectomy owing to benign enlargement of the prostate. Followup averaged 7 years and included 91 patients with 122 direct and indirect, unilateral or bilateral hernias. Summation of our results shows a low recurrence rate (4.9 per cent) and no complications in the wake of the combined operation. In our opinion prostatectomy combined concurrently with inguinal hernia repair via a preperitoneal retropubic approach should be applied routinely in urological practice.

Ectopic Splenic Tissue Simulating a Renal Mass

A 64-year-old patient who underwent splenectomy presented clinically with ectopic splenic tissue simulating a solid renal mass. The splenic origin of the mass was assessed by radionuclide spleen scan. Nephrectomy was avoided.

Efficacy and safety of a novel disposable intravaginal device for treating stress urinary incontinence.

OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of a novel disposable intravaginal device for treatment of stress urinary incontinence (SUI) in women. STUDY DESIGN Sixty women with severe SUI were recruited from 2 sites in Israel to wear preweighed pads during a 7-day control period followed by a 28-day device usage period in which the device and preweighed pads were worn daily for 8 hours. The primary endpoint was the percentage of women who achieved a > or = 70% reduction in pad weight gain (PWG) from the control period to the last 14 days of device usage. RESULTS Sixty women who enrolled into the study and used the device for any period of time were included in the intent to treat (ITT) population. Eighty-five percent of them achieved a > or = 70% reduction in PWG (P = .01). Improvements in overall quality of life, subjective perception of incontinence, and satisfaction with the device were observed. CONCLUSION The intravaginal device is easy to use, well-tolerated, and effective in reducing SUI.

Surgical management of long urethral strictures

A total of 25 patients with a long urethral stricture involving the bulbomembranoprostatic urethra underwent excision of the afflicted region via the perineal approach with end-to-end anastomosis. Liberation of the distal urethra provided sufficient length for anastomosis without tension of the healthy urethra. Satisfactory results were obtained in 23 of the 25 patients without any functional disturbance of sphincter control.

THE LEAK SCORE – A NOVEL INSTRUMENT TO ASSESS SUBJECTIVE SEVERITY OF FEMALE STRESS URINARY INCONTINENCE AND EFFICACY OF TREATMENT

Study design, materials and methods A novel, disposable, flexible intra-vaginal device for the conservative treatment of SUI in women was tested for efficacy, safety and quality of life. Sixty women with severe SUI were recruited to wear pre-weighed pads, initially during a 7-day control period, and then during a subsequent 28-day device usage period. Pads were worn for 8h daily, during the daytime. The Leak Score, an author compiled scoring system, was used to measure the perception of leakage by assessing the influence of 8 different effort demanding activities coughing, laughing, sneezing, walking, running, jumping, lifting and gymnastics on urinary leakage. Possible responses were “not at all”, “slightly”, “moderate”, “greatly”, and “irrelevant”, respectively scored as 0, 1, 2, 3, and NA. Additional study endpoints were the % reduction of PWG, the percentage of women who achieved ≥ 70% PWG reduction, and the percentage of patients reporting any incontinence episodes on any particular day. Quality of life was assessed by using IIQ-7 & UDI-6 questionnaires.