Mohamed A. Gomha

Critical Evaluation of the Problem of Chronic Urinary Retention After Orthotopic Bladder Substitution in Women

PURPOSE We studied the possible causes of chronic retention after radical cystectomy and orthotopic bladder substitution in women. MATERIALS AND METHODS Between January 1995 and January 2001, 136 women with a mean age plus or minus standard deviation of 52 +/- 8 years underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Videourodynamics, pelvic floor electromyography, pelvic floor magnetic resonance imaging and pan-endoscopy were done. In the last 37 cases some technical modifications were adopted to circumvent the development of chronic urinary retention. RESULTS One woman died postoperatively of massive pulmonary embolism. Of the 100 patients evaluable at a mean followup of 36 months 95 were continent in the daytime, 86 were continent at night, 2 were completely incontinent and 16 were in chronic retention. Videourodynamics showed that retention was mechanical in nature due to the pouch falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction. In addition, herniation of the pouch wall through the prolapsed vaginal stump was observed in most cases. Pelvic floor electromyography demonstrated complete pelvic floor silence during voiding. No abnormality of the pelvic floor or rhabdosphincter was noted on magnetic resonance imaging. Pan-endoscopy showed a normal urethra with no urethroileal stricture. A 4 mg. dose of the alpha1-adrenergic blocker doxazosin daily was ineffective, excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal urethral muscles may have been the cause of this problem. After omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at cystectomy the incidence of chronic retention decreased from 18.7% (14 of 75 cases) before to 8% (2 of 25) after modifications. Furthermore, after vaginal wall descent was mechanically corrected by a pessary there was significant improvement in evacuation. CONCLUSIONS Strong evidence was provided that chronic urinary retention after orthotopic substitution is due to anatomical rather than to functional or neurogenic reasons. Modifications to increase back support of the pouch with ventral suspension near its dome and support the vaginal stump are recommended to avoid this complication.

Treatment of symptomatic simple renal cysts by percutaneous aspiration and ethanol sclerotherapy

To report our experience with the use of 95% ethanol as sclerotherapy for symptomatic simple renal cysts.

NOCTURNAL ENURESIS IN MEN WITH AN ORTHOTOPIC ILEAL RESERVOIR: URODYNAMIC EVALUATION

PURPOSE We evaluated the urodynamic features of enuretic and continent patients with an orthotopic neobladder. MATERIALS AND METHODS Included in our study were 100 men with an orthotopic hemi-Kock or W neobladder and a minimum followup of 1 year. Of the patients 50 were completely continent day and night, and 50 had enuresis without evidence of an underlying organic etiology, such as stones, reflux or urethral stricture. RESULTS Univariate analysis showed significantly higher pressure and a larger volume of post-void residual urine in the men with enuresis. In addition, maximum urethral pressure, maximum flow and compliance were decreased in the enuretic group compared to the continent group. Multivariate analysis revealed that post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions are the most critical parameters affecting nocturnal continence. CONCLUSIONS The cystometric parameters significantly associated with nocturnal enuresis in patients with an orthotopic reservoir are post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions. Urethral pressure and flow parameters did not sustain significance on multivariate analysis.

THE RELATIONSHIP OF THE INTERNATIONAL PROSTATE SYMPTOM SCORE AND OBJECTIVE PARAMETERS FOR DIAGNOSING BLADDER OUTLET OBSTRUCTION. PART I: WHEN STATISTICS FAIL

PURPOSE We evaluated the International Prostate Symptom Score and correlated it with objective means of determining bladder outlet obstruction. MATERIALS AND METHODS Beginning in May 1996, 460 men 41 to 88 years old (mean age plus or minus standard deviation 60.4 +/- 9.4) were prospectively included in this study. Symptoms were evaluated using the International Prostate Symptom Score, and digital rectal examination, outpatient cystoscopy, prostate specific antigen determination and transrectal ultrasound were done. Urodynamic evaluation included uroflowmetry, filling cystometry and pressure flow study. RESULTS Linear regression was done to correlate scores with measurable parameters. We noted no correlation of the total, obstructive symptoms or irritative symptoms score with objective parameters, including the average and maximum flow rate, post-void residual urine, prostate size and Schäfer grade. CONCLUSIONS Prostatic symptom scores are qualitative. Using them to quantify the degree of obstruction or evaluate therapy is questionable.

The Relationship of Detrusor Instability and Symptoms With Objective Parameters Used for Diagnosing Bladder Outlet Obstruction: A Prospective Study

PURPOSE Detrusor instability is a common urodynamic finding in patients with prostatic obstruction. In prospective fashion we evaluated detrusor instability in patients with lower urinary tract symptoms attributable to benign prostatic hyperplasia and determined its possible association with the degree of obstruction. MATERIALS AND METHODS A total of 459 men with a mean age plus or minus standard deviation of 60.4 +/- 9.4 years who were investigated for lower urinary tract symptoms at our facility answered an Arabic standardized version of International Prostate Symptom Score and underwent simple uroflowmetry, outpatient cystoscopy and transrectal ultrasound. Invasive urodynamics, including filling and voiding cystometry, was done with pressure flow analysis according to the Schäfer nomogram. Statistical significance was tested by the Mann-Whitney U and Wilcoxon rank sum tests. RESULTS Of the 459 patients 108 (23.5%) had detrusor instability. Instability significantly affected patient symptom score and conception of quality of life. Moreover, instability significantly affected the degree of obstruction, as measured by the maximum flow rate, post-void residual urine, prostate volume and Schäfer grade of obstruction. CONCLUSIONS Detrusor instability affects patient symptoms and quality of life. It also signifies a more severe degree of obstruction in male patients with lower urinary tract symptoms and bladder outlet obstruction due to benign prostatic hyperplasia.

Urethral pressure profile following orthotopic neobladder: differences between nerve sparing and standard radical cystectomy techniques.

PURPOSE Some authors reported that adopting a nerve sparing technique during radical cystoprostatectomy improves the continence outcome of orthotopic diversion in patients with invasive bladder carcinoma. We urodynamically evaluated the effect of nerve sparing cystoprostatectomy on external urethral sphincteric function. MATERIALS AND METHODS A total of 30 consecutive male patients who underwent nerve sparing cystoprostatectomy and ileal neobladder (NS group) were compared to a control group of 30 patients who underwent a similar procedure but without nerve sparing (non-NS group). Continence status was thoroughly clinically evaluated in parallel to erectile function in both groups. The urethral sphincteric mechanism was evaluated with urethral pressure profilometry in different positions. RESULTS Better urethral pressure profile parameters were found in patients in the NS group. Significantly longer functional urethral length (34.8 mm) was detected in NS group than in the non-NS group (30.1 mm). Moreover, the maximum urethral pressure was higher in the NS group but not to a statistically significant level. In the NS group there were no statistically significant differences between potent and impotent subgroups regarding the continence rate or urethral pressure parameters. CONCLUSIONS There is urodynamic evidence that the nerve sparing technique improved urethral sphincteric function and, consequently, the continence rate. The denervated, most proximal part of the urethra in non-NS cases with lack of contraction and, therefore, any pressure, is a possible explanation for the difference in UPP.

Prognostic value of angiogenesis in schistosoma-associated squamous cell carcinoma of the urinary bladder

OBJECTIVES To evaluate angiogenesis as a prognostic marker in squamous cell carcinoma of the urinary bladder in 154 patients who underwent radical cystectomy. METHODS The tumors from 98 men and 56 women (mean age 46.3 +/- 8.4 years) were examined. Vessels were stained using an antibody to the platelet endothelial cell adhesion molecule CD31. Microvessels were counted in active areas of angiogenesis within the tumors. Microvessel density (MVD) was quantified using the mean of three counts. Age, sex, tumor grade and stage, DNA ploidy, and MVD were evaluated in relation to outcome. Univariate and multivariate analyses of survival were performed. RESULTS The median follow-up period was 63 months. The overall 5-year survival rate was 56 +/- 4.1. Tumor grade, tumor stage, DNA ploidy, and MVD had a significant impact on the survival of patients in univariate analysis. The 5-year survival rate in patients with a low MVD (11 or less) was 68.1% compared with 50.4% for those with a high MVD (greater than 11; P <0.01). Men had more vascular tumors than did women. Also, high-grade tumors had significantly higher vascular counts. In a Cox proportional hazard model, tumor angiogenesis sustained its significant impact on survival of the patients in addition to tumor stage and DNA ploidy. CONCLUSIONS These findings suggest that angiogenesis and DNA ploidy are independent additional prognostic factors in patients with squamous cell carcinoma of the urinary bladder.

Prognostic significance of tumour angiogenesis in schistosoma-associated adenocarcinoma of the urinary bladder.

Objective To report on tumour angiogenesis and its relationship with morphological variables and prognosis in adenocarcinoma of the urinary bladder associated with schistosomiasis.

Clinical and urodynamic efficacy of oxybutynin and verapamil in the treatment of nocturnal enuresis after formation of orthotopic ileal neobladders : A prospective, randomized, crossover study

Objective. To evaluate the efficacy of two drugs: the anticholinergic agent oxybutynin (Ditropan) and the calcium channel blocker verapamil (Isoptin) in the management of nocturnal enuresis in patients with orthotopic ileal reservoirs. Material and methods. The study population comprised 20 male enuretic patients who had undergone radical cystoprostatectomy and formation of an orthotopic ileal reservoir (hemi-Kock or W-neobladder). All patients were clinically evaluated regarding their continence state. Basal medium-fill enterocystometry was performed for every patient. The patients were randomized on entry into one of the two arms of the study: oxybutynin followed by verapamil (n=10); or verapamil followed by oxybutynin (n=10). Each group received both drugs for a period of 2 weeks each. After administration of each drug, patients were re-evaluated both clinically and urodynamically. Results. Oxybutynin and verapamil improved continence status in 70% and 55% of the patients, respectively. Both drugs significantly increased the bladder volume at first desire, at normal desire and at the maximum enterocystometric capacity. The maximum enterocystometric capacity increased from 585±148.6 ml at baseline to 667.5±180.8 and 621.05±170.5 ml after administration of oxybutynin and verapamil, respectively. Despite this, there was no significant change in any of the pressure parameters with the exception of the basal pressure at maximum enterocystometric capacity, which decreased significantly from 20.1±8.3 cmH2O at baseline to 16.07±5.1 cmH2O after administration of verapamil. The number of uninhibited contractions in the last 5 min of filling decreased significantly from 3.6±0.7 at baseline to 1.9±1.2 after administration of oxybutynin and to 2.1±1.26 after administration of verapamil. The amplitude of maximum uninhibited contraction decreased from 41.15±9.1 cmH2O at baseline to 34.95±12.77 and 33.25±11.52 cmH2O after treatment with oxybutynin and verapamil, respectively. Neither drug significantly changed the initial, late or total compliance of the pouch. No significant side-effects occurred with either drug. Conclusions. Both drugs used in this study had beneficial effects on the continence status of our patients, with minimal side-effects. Both drugs clinically improved nocturnal incontinence after radical cystoprostatectomy and formation of orthotopic ileal reservoirs, which was verified by the associated improvements in urodynamic characteristics.

Persistent and occasional nocturnal enuresis in orthotopic urinary diversion: is there a urodynamic difference?

Authors from Mansoura attempted to determine the urodynamic criteria differentiating patients who have an ileal neobladder and who are either persistently enuretic or are occasionally enuretic. They found that all enuretic patients had significantly higher residual urine volumes than continent patients, and that there were differences in the two groups of enuretics, suggesting areas that can be targeted therapeutically.