Michael Kennelly

Outcome Analysis of 42 Cases of Renal Angiomyolipoma

Angiomyolipomas were found in 42 kidneys in 23 female and 8 male patients at our medical center. Angiomyolipoma was diagnosed by computerized tomography (CT) alone in 55% of the cases, and by a combination of ultrasound and CT in 36%. Nine of 11 patients with bilateral angiomyolipoma had associated tuberous sclerosis. Treatment consisted of observation in 22 patients, selective arterial embolization in 6, partial nephrectomy in 6 and nephrectomy in 8. A total of 17 patients who were observed had tumors smaller than 4 cm. and 4 h had angiomyolipoma of 4 to 10 cm. With a mean followup of 3.8 years, no observation patient had subsequent renal hemorrhage and only 1 (tumor larger than 10 cm.) had radiographic progression. Despite progression, the latter patient remained asymptomatic for 18 years. Selective arterial embolization (3 tumors 4 to 10 cm. and 3 larger than 10 cm.) resulted in preservation of renal function at a mean of 1 year. All patients treated with partial nephrectomy (6 tumors 4 to 10 cm.) maintained stable renal function without recurrence during a mean 4.7-year followup. Similarly, all individuals who underwent nephrectomy (4 tumors smaller than 4 cm., 3 tumors 4 to 10 cm. and 1 tumor larger than 10 cm.) have stable renal function. We recommend renal conservation for patients with renal angiomyolipoma using a strategy of observation for small asymptomatic tumors, partial nephrectomy for moderate size tumors and selective arterial embolization of large tumors not amenable to partial nephrectomy.

Endoscopic injection of glutaraldehyde cross-linked collagen for the treatment of intrinsic sphincter deficiency in women.

OBJECTIVES To determine the clinical efficacy, safety, and durability of endoscopically injected glutaraldehyde cross-linked (GAX) collagen for the treatment of intrinsic sphincter deficiency (ISD) in women. METHODS Forty-two women with a mean age of 64 years (range, 28 to 88) underwent injection of GAX collagen for ISD. Collagen was injected via a transurethral or periurethral approach. Treatment outcome was based on the change in stress leak point pressures (SLPP) and individual incontinence grades before and after collagen injection. RESULTS With a mean follow-up of 46 months (range, 10 to 66), 83% were cured (n = 17), greatly improved (n = 5), or improved (n = 13), and 17% were unchanged (n = 3) or worse (n = 4). The median number of treatments was 2 (range, 1 to 8). The 22 women greatly improved or cured required a mean of 2.4 collagen injection treatments, whereas the 20 women who were improved, unchanged, or worse had a mean of 4.1 treatments (P = 0.009). The mean amount of collagen injected per patient was 28.3 cc (range, 2.5 to 85). The group of women who were greatly improved or cured had a mean of 17.5 cc of collagen injected, whereas those who were improved, unchanged, or worse had a mean of 39.5 cc injected (P = 0.002). Mean pretreatment SLPPs of women improved, greatly improved, or cured versus the women unchanged or worse were not significantly different (P = 0.015). The 35 women who were improved or cured had a significant increase in mean SLPP of 65.4 cm H2O (P = 0.001) compared to a mean change in SLPP of 14.7 cm H2O in those women who were unchanged or worse (P = 0.038). CONCLUSIONS GAX collagen injection for the treatment of stress urinary incontinence secondary to ISD appears to be safe, effective, and durable; hence, it should be considered the treatment of choice in appropriately selected female patients.

Outcome analysis of bilateral cohen cross-trigonal ureteroneocystostomy

OBJECTIVES The perioperative and long-term outcomes of children with vesicoureteral reflux (VUR) treated by cross-trigonal ureteroneocystostomy were ascertained. METHODS One hundred ten consecutive children with VUR who underwent bilateral cross-trigonal ureteroneocystostomy were studied retrospectively. Nineteen children with neurovesical dysfunction or megaureters requiring tapered reimplants were excluded. Outcome parameters of the remaining 91 children consisted of operative time, length of hospitalization, days of Foley catheter drainage perioperative complications, correction of reflux, subsequent morbidity, and parental satisfaction. RESULTS Of 182 renal units, 11 (6%) had grade 0 VUR, 18 (10%) had grade I, 43 (24%) had grade II, 59 (32%) had grade III, 36 (20%) had grade IV, and 15 (8%) had grade V reflux. The mean operative and hospitalization times were 180 minutes and 5.6 days, respectively. No postoperative complications occurred. Three children were lost to follow-up, and the remaining 88 children had an extended mean follow-up in excess of 3 years. Voiding cystourethrogram documented a 98.3% (173 of 176 renal units) success rate. Sixteen children (18%) experienced nonfebrile clinically symptomatic cystitis episodes and 3 children (3%) experienced one febrile episode each. Telephone parental survey of overall surgical experience revealed a 94% very satisfied, 2% satisfied, and 3% dissatisified rate. CONCLUSIONS Cross-trigonal ureteroneocystostomy is a safe and effective technique that is virtually complication free and has high parental satisfaction. The results of this study provide a baseline for comparison of non-operative treatment of reflux as well as laparoscopic and endoscopic techniques.

Incontinent ILEO-Vesicostomy Urinary Diversion in the Treatment of Lower Urinary Tract Dysfunction

The combination of high spinal cord injury and neurovesical dysfunction can present formidable problems in urological management. The lack of upper extremity function often prevents intermittent catheterization and leads to alternative methods. A total of 23 patients underwent incontinent ileo-vesicostomy in an effort to gain a low pressure bladder and control of urinary soiling: 17 had been previously treated by catheter drainage, 9 had bladder and/or renal calculi, 9 experienced recurrent sepsis, and 7 had urethrocutaneous fistula and total urinary incontinence. Most patients had poorly compliant bladder dysfunction associated in 9 cases with poor urethral continence function. At a mean followup of 45 months (range 3 to 240 months) 22 of 23 patients had a low pressure reservoir with low pressure degrees of urine into a collection device. Complications included stomal stenosis in 3 patients and poor drainage across the ileovesical junction requiring revision in 2. One of these patients ultimately underwent ileal loop diversion. Upper tract function improved or remained stable in all patients.

Early clinical experience with adult bladder auto-augmentation

Five patients 18 to 73 years old underwent auto-augmentation for a small capacity, poorly compliant bladder. The mean operative time and hospital stay were 106 minutes and 6 days, respectively. No postoperative complications occurred. Followup ranged from 12 to 82 weeks. Bladder capacity increased from 75 to 310 cc or 40 to 310%. Compliance also improved in all patients. Three patients had reflux preoperatively, which resolved in 1 and improved in 2. Of 4 patients who were incontinent preoperatively 3 became continent postoperatively and extended the interval between catheterizations. Upper tract function has remained stable. No patient required enterocystoplasty to control bladder pressures.

Vardenafil improves ejaculation success rates and self-confidence in men with erectile dysfunction due to spinal cord injury.

Study Design. Multicenter, double-blind, placebo-controlled, parallel-group study. Objective. To assess the effect of the oral phosphodiesterase type-5 inhibitor, vardenafil, on ejaculation rates and self-confidence in men with spinal cord injury (SCI). Summary of Background Data. Spinal command of male sexual functions is often seriously impaired by traumatic spinal cord injury (SCI). A high proportion of men with SCI cannot ejaculate during sexual intercourse. SCI-related ejaculatory disorders are often responsible for male infertility. Sexual dysfunction associated with SCI can also affect mens self-confidence. Methods. In this 12-week study, 418 men aged ≥18 years with erectile dysfunction >6 months resulting from a traumatic SCI were randomized to vardenafil (n = 207) or placebo (n = 211) 10 mg for 4 weeks, then maintained or titrated to 5 or 20 mg at weeks 4 and 8. Assessments included questions of the International Index of Erectile Function (IIEF) about ejaculation success and orgasmic perception; the Global Confidence Question; and quality-of-life scales to measure psychological well-being, self-esteem, depression, and mental health status. Results. Overall per patient ejaculation success rates were significantly greater with vardenafil than placebo over 12 weeks of treatment (19% vs. 10%; P < 0.001). At last observation carried forward, the IIEF “orgasmic function” score increased from 2.9 at baseline to 4.0 for vardenafil and from 3.0 at baseline to 3.4 for placebo. Sixteen percent of men receiving vardenafil and 8% receiving placebo felt orgasm “almost always” or “always” at weeks 8–12, compared with 4% and 6%, respectively, at baseline. Significant improvements in confidence scores were observed with vardenafil compared with placebo (P < 0.0001). There were no clinically significant differences between vardenafil and placebo in the quality-of-life measures at the study endpoint, but these had been in the normal range at baseline. Conclusion. Vardenafil significantly improved ejaculation and self-confidence in men with erectile dysfunction due to SCI.

Efficacy and safety of oxybutynin transdermal system in spinal cord injury patients with neurogenic detrusor overactivity and incontinence: an open-label, dose-titration study.

OBJECTIVES To evaluate the efficacy and safety of oxybutynin transdermal system (oxybutynin-TDS) in spinal cord injury patients with neurogenic detrusor overactivity and incontinence despite use of clean intermittent catheterization (CIC). METHODS This multicenter, open-label, dose-titration study included patients > or = 18 years old. During an 8-week dose-titration period, oxybutynin-TDS doses were adjusted every 2 weeks, depending on symptoms. The primary efficacy end point was a change in daily number of CIC periods without leakage, from baseline to 8 weeks or last observation. Outcome parameters included 3-day voiding diary, CIC volume, and urodynamic parameters. Changes from baseline were analyzed with paired t tests. RESULTS Of 24 study participants (mean age, 41.9 years), 18 (75.0%) completed the study. Final oxybutynin-TDS doses were 7.8, 9.1, and 11.7 mg/d for 4, 9, and 11 patients, respectively. Daily number of CIC periods without leakage increased significantly (mean change, 1.5 + or - 2.2; P = .0036) from baseline (2.4 + or - 1.8) to 8 weeks (3.9 + or - 1.9). CIC volume (P = .0029), reflex volume (P = .0466), maximal cystometric bladder capacity (P = .0009), and residual urine volume (P = .0023) all increased significantly, whereas detrusor pressure at maximal bladder capacity decreased significantly (P = .0457). The most common adverse events were application site reaction (12.5% of patients), dry mouth (8.3%), and abnormal vision (8.3%). No patient discontinued treatment because of an adverse event. CONCLUSIONS Oxybutynin-TDS was efficacious in spinal cord injury patients with neurogenic detrusor overactivity and was well tolerated at up to 3 times the standard dose.

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long‐term extension study

To present final efficacy/safety results from a prospective, long‐term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years.

Vesicopyeloplasty in renal transplant patients : a 20-year followup

Loss of a ureter in a renal transplant patient often results in transplant nephrectomy. In 1973 we used vesicopyelostomy with the bladder directly sutured to the renal pelvis as a method of reconstruction in 2 renal transplant patients following ureteral loss. These patients have been followed for more than 20 years and both renal allografts have functioned well. The status of these patients and a review of the literature on vesicopyelostomy are presented.

PERINEPHRIC URINOMA SECONDARY TO NEUROGENIC BLADDER IN MYELODYSPLASIA

We report on a girl with infected perinephric urinoma and myelodysplasia who presented with a febrile urinary tract infection. A complex perinephric fluid collection with internal echoes was found on renal ultrasound, necessitating placement of a percutaneous drainage tube. Initial urodynamic testing after treatment of the infection revealed a noncompliant bladder with an elevated detrusor leak point pressure. Neurovesical dysfunction with elevated leak point pressure is believed to be the cause of urinoma. Clinical presentation, treatment and pathophysiology of this entity are discussed.