L. Paul Sonda

Experience with Pubovaginal Slings for Urinary Incontinence at the University of Michigan

In July 1983 pubovaginal slings were used first at our university to treat incontinence in female patients with poor urethral function. From then until July 1, 1986, 82 such procedures were performed on a diverse group of patients, including a male patient. Initial success occurred postoperatively in 67 patients, with 15 failures. Of these failures 7 were related to urethral dysfunction. Another sling procedure was done in 2 patients and they are continent, while 3 were treated with medication: 2 became dry and 1 remains wet. A total of 8 patients suffered detrusor-related incontinence postoperatively (2 required augmentation cystoplasty for poor bladder compliance). To date 78 patients (95 per cent) are continent. Of the patients 2 required periodic intermittent catheterization for more than a year postoperatively and 12 are managed by chronic intermittent self-catheterization on a planned basis for neurogenic vesical dysfunction.

Ureteral Stone Management: Emerging Concepts

A total of 206 procedures was performed on 193 patients with ureteral calculi. The success rate was 62 per cent for stones proximal to the pelvic brim and 94 per cent for stones distal to the pelvic brim (87 per cent success over-all). Of the procedures 61 were done for fragments lodged in the ureter following extracorporeal shock wave lithotripsy. Ureteroscopy was done in 147 cases. Our current management concepts (including extracorporeal shock wave lithotripsy) for proximal and distal ureteral calculi are presented.

Fate of Patients Started on Clean Intermittent Self-Catheterization Therapy 10 Years Ago

We evaluated 60 patients placed on a clean intermittent catheterization program more than 10 years ago to determine their outcome. To date 27 patients still are performing self-catheterization, 18 have discontinued the procedure and 15 have been lost to followup. No patient has had deterioration in renal function. Prior incontinence was alleviated completely in 10 of the 27 patients still on the program and 10 of the 18 patients no longer on catheterization have returned to normal voiding. Clean intermittent catheterization is an effective treatment modality in properly selected patients, with few complications and excellent long-term results.

The role of yohimbine for the treatment of erectile impotence

A double-blind crossover study of yohimbine vs. placebo was carried out in 40 patients. Eleven of 33 patients (33%) who completed the study had subjective improvement of erection while taking yohimbine alone, five of 33 (15%) responded while taking both yohimbine and placebo, five of 33 (15%) responded to placebo alone, and 12 of 33 (36%) responded to neither. Of 215 impotent patients subsequently treated with yohimbine, 38% reported some subjective improvement, but only 5% were completely satisfied. The physiologic response of yohimbine appears to occur in the central nervous system. Recent experience suggests that the typical dose has little side effect and higher doses achieves better results, but this conclusion requires more evaluation.

Treatment of renal transplant stones byextracorporeal shock-wave lithotripsy in the prone position

Two patients with renal transplant lithiasis were successfully treated with extracorporeal shock-wave lithotripsy (ESWL) in the prone position. Pathogenesis and treatment of transplant lithiasis are discussed. Performing ESWL on renal transplant patients in the prone position has advantages over standard positioning techniques.

Compatibility of Genitourinary Prostheses and Intermittent Self-catheterization

The compatibility of genitourinary prostheses and intermittent self-catheterization was established in 13 prosthetic recipients who were concomitantly on intermittent self-catheterization for bladder emptying dysfunction. All patients were able to catheterize themselves successfully after implantation of the prosthesis. No prosthetic infection was encountered in our series. Two penile prosthetic recipients suffered unilateral epididymitis that was treated successfully. Although mechanical complications were encountered they were repaired readily and were not considered related to self-catheterization.

Further Observations on the Cystometric and Uroflowmetric Effects of Bethanechol Chloride on the Human Bladder

We evaluated the cystometric and uroflowmetric effects of bethanechol chloride on non-neurogenic, non-decompensated human bladders. Statistically significant changes were measured using cystometric and uroflowmetric parameters. We discuss the indications and methods for therapy with bethanechol chloride.

Treatment of Painful Caliceal Stones

Nonmobile caliceal stones cause pain more often than previously appreciated. The character and intensity of the pain differs from typical renal colic. Twenty-six patients with caliceal stones and pain underwent attempted treatment for pain control via stone removal or disintegration: 15 were treated with percutaneous stone extraction (PSE), 10 with extracorporeal shock-wave lithotripsy (ESWL), and 1 required open surgery after failing PSE. One patient had persistent pain after ESWL and subsequently underwent PSE; 25 of 26 patients had complete relief of pain. Morbidity was minimal. Patients with painful caliceal stones should be offered ESWL, followed by PSE if pain persists.

Long-term followup of the artificial urinary sphincter.

The artificial urinary sphincter with a pressure regulating balloon was implanted in 30 patients. All implantations were done before September 1982, for a minimum followup of 1 year and an average followup of 3.7 years. Of the patients 21 (70 per cent) have a functioning sphincter: 17 are continent and 4 are slightly incontinent, requiring 1 pad per day. Failure was owing to erosion in 6 patients and infection of the device in 3. Critical factors for successful implantation include preoperative evaluation, cuff location and pressure, primary deactivation and postoperative care. Our experience supports the further use of this device in appropriate cases.

Initial clinical trials with a tubless lithotriptor.

The Medstone 1050 is a new tubeless lithotriptor developed in the United States. Under Food and Drug Administration guidelines a human treatment protocol has been developed. The first 50 patients treated at a single site and followed for a minimum of 3 months are presented. All stones treated were 3 cm. or less in longest dimension and located in the renal pelvis, calices or proximal ureter. An adequate fragmentation rate of 90% was achieved in this group. There were no significant complications in any patient. A larger multicenter study presently is underway.