Rajesh V. Patel

BILATERAL LAPAROSCOPIC INGUINAL HERNIA REPAIR CAN COMPLICATE SUBSEQUENT RADICAL RETROPUBIC PROSTATECTOMY

We report a case in which pelvic lymphadenectomy and radical retropubic prostatectomy were aborted because the pelvic side walls and Retzius’ space were obliterated by polypropylene mesh that had been placed during bilateral laparoscopic inguinal hernia repair 3 years previously. To our knowledge our case represents the first report of this problem, and we believe that bilateral laparoscopic inguinal hernia repair makes subsequent radical retropubic prostatectomy more difficult, if not impossible.

Use of new technology in endourology and laparoscopy by American urologists: Internet and postal survey

OBJECTIVES To assess the use of new technology by American urologists. METHODS Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory. RESULTS Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001). CONCLUSIONS Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.

Practice patterns in the treatment of female urinary incontinence: a postal and internet survey

OBJECTIVES To survey American urologists to assess practice patterns in treating female incontinence. Advances in the treatment of female incontinence have changed the way urologists practice. METHODS Postal and e-mail surveys were sent to 2502 members of the American Urological Association. RESULTS From the postal group (n = 1000), 419 (42%) responses were obtained; from the e-mail group (n = 1502), 160 (11%) responses were obtained. For types I, II, and III stress urinary incontinence (SUI), 239 (44%) of 546, 388 (68%) of 570, and 512 (94%) of 547 urologists, respectively, recommended a sling procedure. For type I SUI, 75 (53%) of the 143 respondents in practice for less than 10 years recommended a sling procedure. The sling was recommended by 62 (35%) of the 176 respondents in practice for longer than 20 years (P <0.001). Most urologists (75%, 358 of 480) referred patients with significant vaginal prolapse to a gynecologist; however, urologists in full-time academic practice were more likely to offer surgical treatment (56%, 29 of 52). Most urologists recommended medical treatment for urge incontinence (94%, 461 of 491), and the medications most commonly selected were tolterodine (41%, 202 of 491), oxybutynin (26%, 129 of 491), and extended-release oxybutynin (25%, 125 of 491). CONCLUSIONS Overall, a sling procedure was the most commonly recommended surgical procedure for all types of SUI. Most urologists referred patients with significant vaginal prolapse to a gynecologist. For type I SUI, older urologists were more likely than younger urologists to perform needle bladder neck suspension.

INTERNET AND POSTAL SURVEY OF ENDOUROLOGIC PRACTICE PATTERNS AMONG AMERICAN UROLOGISTS

PURPOSE We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger). MATERIALS AND METHODS Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster. RESULTS Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents. CONCLUSIONS Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.

Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery

OBJECTIVES To compare the efficacy of single-dose oral ciprofloxacin with intravenous cefazolin as a prophylactic agent in patients undergoing outpatient endourologic surgery. METHODS One hundred patients were enrolled in a double-blind, randomized study to receive either ciprofloxacin (500 mg) or cefazolin (1 g) before surgery. A postoperative clinical evaluation and urine cultures were performed 5 to 10 days after surgery. Patients undergoing ureteral stent insertion or exchange, ureteroscopy, bladder biopsy, retrograde pyelography, collagen injection, and internal urethrotomy were included. RESULTS Postoperative urinary tract infection occurred in 7 (9.1%) of 77 patients, including 3 (8.1%) of 37 and 4 (10.0%) of 40 of those who received ciprofloxacin and cefazolin, respectively (P = 0.77). There were no episodes of sepsis, and no patient with infection required hospitalization. The total cost associated with the administration of prophylactic antibiotics in the study population was

Comparison of the durability of cadaveric and autologous fascia using an in vivo model

3657 less in those 50 patients who received ciprofloxacin than in the 50 patients who received cefazolin. CONCLUSIONS A single oral dose of ciprofloxacin in patients undergoing outpatient endourologic surgery was equally effective as cefazolin in preventing postoperative urinary tract infection, but was associated with markedly lower overall costs.

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

OBJECTIVES To assess the durability of both autologous and cadaveric fascia using an animal model. The pubovaginal sling procedure can be performed using autologous, cadaveric, or synthetic materials. Few data are available about the strength and durability of these materials. METHODS Rectus abdominus fascia harvested from 6 female Sprague-Dawley rats was processed by Tutogen Medical. In 20 female Sprague-Dawley rats, three different types of fascia were implanted subcutaneously into each animal: autologous rectus abdominus fascia harvested at the time of surgery; rat cadaveric fascia processed by Tutogen; and human cadaveric fascia (Tutogen). The rats were killed at 2 months (10 rats) and 4 months (10 rats) after implantation. The mechanical properties of the tissue were assessed using the trouser tear test, and the fracture toughness was calculated. RESULTS Compared with the fracture toughness before implantation, the implanted rat autologous fascia decreased in toughness from 1763 to 1243 J/m(2) (P = 0.12), the implanted rat cadaveric fascia decreased in toughness from 1539 to 1022 J/m(2) (P = 0.02), and the implanted human cadaveric fascia decreased in toughness from 2120 to 1145 J/m(2) (P = 0.09). The fracture toughness of the implanted rat cadaveric fascia and rat autologous fascia did not differ significantly (P = 0.29). CONCLUSIONS The changes in strength or elasticity can be detected using the trouser tear test to calculate the fracture toughness. Both cadaveric and autologous fascial grafts may decrease in toughness with time. The long-term durability of the graft may only be a minor factor in determining the success of the pubovaginal sling procedure.