R. Corey O’Connor

Long-term Follow-up of Single Versus Double Cuff Artificial Urinary Sphincter Insertion for the Treatment of Severe Postprostatectomy Stress Urinary Incontinence

OBJECTIVESnTo assess the long-term effectiveness and complications associated with single and double cuff artificial urinary sphincter (AUS) implantation for the treatment of severe postprostatectomy stress urinary incontinence (SUI).nnnMETHODSnWe updated the outcomes of 56 men with postprostatectomy SUI who underwent single (28 patients) or double (28 patients) cuff AUS placement. Originally patients in each cohort were matched according to preoperative pad usage, risk factors for complications, and age. Continence, quality of life, and complications were assessed according to the Incontinence Impact Questionnaire Short Form (IIQ-7), postoperative pad usage, chart review, and patient/family interview.nnnRESULTSnUpdated data were available for 47 men (25 single cuff and 22 double cuff patients). Mean pre-AUS implant age was 67 years for each group. Average follow-up was 74.1 months and 58.0 months for single and double cuff patients, respectively. No statistically significant difference in continence improvement was noted between the two groups according to daily pad usage and overall dry rate. IIQ-7 scores improved from 14.8 to 4.1 after single cuff implants and from 16.3 to 6.4 after double cuff placement (P = 0.34). Men receiving a single cuff AUS reported seven complications requiring further operative intervention. Double cuff patients underwent 12 additional surgeries secondary to complications.nnnCONCLUSIONSnDespite our earlier findings, no significant difference in dry rate, overall continence, or quality of life was seen with long-term follow-up of single versus double cuff AUS patients. Furthermore, men receiving double cuff implants may be at higher risk of complications requiring additional surgery.

Antimuscarinic drugs: review of the cognitive impact when used to treat overactive bladder in elderly patients.

The blockade of muscarinic receptors in the management of overactive bladder (OAB) symptoms provides beneficial as well as adverse effects. The cognitive changes observed are caused by the drugs’ ability to cross the blood–brain barrier and bind to muscarinic receptors within the central nervous system (CNS). To date, while not specifically testing for CNS side effects, most of the controlled efficacy trials of multiple OAB medications have not shown significant adverse effects on cognitive function. However, elderly individuals, in whom OAB is more prevalent, often are excluded from these studies. The few trials that have performed cognitive testing in healthy elderly people taking antimuscarinics have clearly shown that oxybutynin can adversely affect cognition. Darifenacin, trospium, solifenacin, and tolterodine appear to have little to no risk of causing CNS side effects in this population. However, caution needs to be used in elderly patients with preexisting dementia.

Objective differences between overactive bladder patients with and without urodynamically proven detrusor overactivity

Introduction and hypothesisThis paper aims to determine if there are differences between female overactive bladder (OAB) patients with and without urodynamic detrusor overactivity (DO).MethodsA retrospective chart review was performed on 146 women with OAB. All patients completed an American Urological Association symptom score, 48-h bladder diary (documenting voided volumes, incontinent episodes, and degree of urgency to void), and urodynamic testing (UDS). Patients with urodynamic DO were then compared to patients without DO.ResultsThere were no differences in symptom scores. Patients with DO (54.1%) were older (61.8 vs. 50.8xa0years) and had smaller maximum voided volumes per void (377xa0mL vs. 476xa0mL), average 24-h urine output (1,975xa0mL vs. 2,320xa0mL), and significantly more incontinent episodes. On UDS, patients with DO were more likely to have abnormal sensation, with strong desire and urgency occurring at significantly lower bladder volumes.ConclusionDespite similar symptomatology, there are objective differences between OAB patients with and without DO.

Novel modification of partial nephrectomy technique using porcine small intestine submucosa

INTRODUCTIONnTo describe a novel partial nephrectomy technique that uses small intestine submucosa (SIS) to ensure a watertight closure of the collecting system and minimize parenchymal bleeding. The indications for nephron-sparing surgery have increased in recent years. The most prevalent complications after partial nephrectomy include urinary leakage/fistula and parenchymal bleeding. Porcine SIS has been used in animal models to reconstruct portions of the urinary tract successfully.nnnTECHNICAL CONSIDERATIONSnTwenty-two consecutive patients underwent 24 partial nephrectomies that required entry into the collecting system for presumed renal cell carcinoma. After temporary occlusion of the renal vessels and renal hypothermia, the tumor and a margin of normal parenchyma were excised. The cut surface was cauterized with an argon beam coagulator, and visible vessels were suture ligated. The collecting system was reapproximated with interrupted, absorbable sutures. A multilayer piece of hydrated SIS was sutured in place over the exposed collecting system and parenchymal defect with several figure-of-eight chromic sutures. With a mean follow-up of 18.4 months, none of the 22 patients experienced postoperative urinary leaks/fistulas or postoperative hemorrhage requiring transfusion. The serum creatinine returned to within 0.2 mg/dL of baseline in all patients after surgery.nnnCONCLUSIONSnWe describe a novel technique of partial nephrectomy using SIS, which, we believe, aids in closure of the collecting system and decreases parenchymal bleeding.

Nonsurgical management of benign prostatic hyperplasia in men with bladder calculi

OBJECTIVESnTo assess the outcome of men with bladder calculi who did not undergo transurethral resection of the prostate after endoscopic stone removal. Bladder calculi associated with benign prostatic hyperplasia (BPH) have historically been an absolute indication for transurethral resection of the prostate.nnnMETHODSnA retrospective analysis of the results of 23 men who underwent endoscopic removal of bladder calculi with subsequent medical management of BPH symptoms was performed. Inclusion criteria included men with bladder stones secondary to BPH, serum creatinine 1.6 mg/dL or less, no evidence of hydronephrosis, and no history of acute urinary retention or neurogenic bladder. The International Prostate Symptom Score and postvoid residual urine volume before and after treatment and the incidence of bladder stone recurrence and associated complications were recorded. All patients were treated with either an alpha-receptor blocker or alpha-receptor blocker and finasteride after bladder stone removal.nnnRESULTSnThe follow-up after endoscopic removal of the bladder calculi averaged 30.0 months (range 6 to 96). The International Prostate Symptom Score before and after treatment was 18.3 and 9.4 (P <0.01), respectively. The postvoid residual urine volume before and after treatment was 354 and 179 mL (P <0.01), respectively. Urinary tract infection, acute urinary retention, recurrent calculi, chronic renal insufficiency, or renal failure developed in 21.7% (n = 5), 17.4% (n = 4), 17.4% (n = 4), 4.3% (n = 1), and 0% (n = 0) of the 23 men, respectively. Overall, 18 (78%) did not have any complications.nnnCONCLUSIONSnMany men with bladder stones can be successfully and safely treated with transurethral stone removal and medical management of BPH.

DISTAL URETERAL REPLACEMENT WITH TUBULARIZED PORCINE SMALL INTESTINE SUBMUCOSA

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.

Nephrolithiasis and nephrocalcinosis in rats with small bowel resection

Intestinal resection (IR) may lead to hyperoxaluria and nephrolithiasis. A rat model of IR was developed, in which kidney stones form. We describe the urine chemistries and histopathologic features. Rats underwent resection of 40–45xa0cm of distal ileum (n=16) or sham resection (SR) (n=8), and were then fed a 1% Na oxalate, 0.02% Ca diet. After 1xa0week on the diet, 24xa0h urine samples were obtained for stone chemistries. At 4–7xa0months after surgery, kidneys were examined grossly and by light microscopy. The extent and location of crystallization was assessed by polarized light. Histochemistry and infrared spectroscopy were used to determine crystal composition. IR rats had higher urine oxalate excretion (P<0.01) and concentration (P<0.001) than SR rats, and lower urine citrate excretion; only IR rats formed kidney stones (12/15 surviving rats). Tissue calcification was found only in kidneys from IR rats, located in the cortex (83% of kidneys), medulla (73%) and papillary tip (47%). Crystals, composed of CaOx, apatite, and calcium carbonate, filled collecting duct lumens, and were associated with tubular obstruction, and interstitial inflammation. Crystals in the papillary interstitium incited inflammation with tubular destruction and development of progressive papillary erosion. This new rat model of nephrolithiasis and nephrocalcinosis resembles the pattern of urinary abnormalities and tissue calcification that may be seen in humans with small bowel resection. The model allows further studies of the mechanisms of renal crystal formation, and possible therapeutic interventions.

Recurrent Giant Cell Carcinoma Of The Bladder

Primary nonurothelial tumors of the bladder are rare, accounting for less than 1% of all bladder cancers.1 To date only 3 cases of osteoclast-like giant cell tumors of the bladder have been reported in the literature.2, 3 Each of these cases was successfully treated with transurethral resection, without evidence of recurrence. To our knowledge we report the first case of recurrent giant cell carcinoma of the bladder.

Artificial urinary sphincter placement in men after cystectomy with orthotopic ileal neobladder: continence, complications, and quality of life

OBJECTIVESnTo review our experience regarding the overall efficacy and safety of an artificial urinary sphincter (AUS) in men with stress urinary incontinence (SUI) after cystoprostatectomy with an orthotopic ileal neobladder.nnnMETHODSnWe performed a retrospective review of 5 men who underwent placement of an AUS (AMS 800) for severe SUI after radical cystectomy with an orthotopic ileal neobladder. Incontinence symptoms and quality of life were quantified using two validated continence questionnaires (Urogenital Distress Inventory Short Form and Incontinence Impact Questionnaire Short Form) and a brief addendum questionnaire. The degree of continence, perioperative and postoperative complications and infections, symptom distress, quality of life, and patient satisfaction were compared before and after AUS placement.nnnRESULTSnComplete (0 pads per day) or social (1 pad or less per day) continence was reported in 5 of 5 patients after AUS placement. The average pad usage significantly decreased from 6.2 to 0.6 per day (P <0.001). No significant perioperative or postoperative complications or infections were noted. Symptom distress, quality of life, and patient satisfaction were significantly improved after AUS placement (P < 0.01, < 0.0001, and < 0.001, respectively).nnnCONCLUSIONSnWith short-term follow-up and a limited number of patients, the placement of an AUS for treatment of SUI after bladder substitution is well tolerated and reliable and has a positive impact on patients quality of life.

Duloxetine for the treatment of post-prostatectomy stress urinary incontinence

OBJECTIVESnStress urinary incontinence (SUI) is a known complication following prostatectomy. Duloxetine, a combined serotonin/norepinephrine reuptake inhibitor, can decrease SUI by increasing urethral sphincter contractility. We examined the outcomes of patients with mild to moderate post-prostatectomy SUI treated with duloxetine.nnnMETHODSnWe conducted a retrospective review of men treated with duloxetine to manage mild to moderate post-prostatectomy SUI from 2006 to 2012. All patients received oral duloxetine 30 mg once a week, then 60 mg thereafter. Patients were seen one month later to determine drug efficacy and side effects.nnnRESULTSnIn total, 94 men were included in the study. Daily pad usage decreased from 2.9 (range: 1-5) to 1.6 (range: 0-4) (p < 0.05). Incontinence Impact Questionnaire (IIQ-7) scores decreased from 13.0 (range: 6-18) to 7.9 (range: 2-16) (p < 0.05). Linear satisfaction scores improved from 0.8 (range: 0-2) to 2.0 (range: 1-3) (p < 0.05). Following a 1-month duloxetine trial, 33/94 (35%) men reported satisfactory SUI improvement and requested to continue the medication. The drug was discontinued in 61/94 (65%) patients due to poor efficacy in 32/94 (34%), intolerable side effects in 14/94 (15%) or both in 15/94 (16%). Reported side effects included fatigue, light-headedness, insomnia, nausea and dry mouth.nnnCONCLUSIONSnDuloxetine improved post-prostatectomy SUI in 47/94 (50%) men following a 1-month trial. However, only 33/94 (35%) patients were able to tolerate the drug. Duloxetine may be considered a treatment option for men with mild to moderate post-prostatectomy SUI.