Rajveer S. Purohit

Urethral Diverticula in Women: Discrepancies Between Magnetic Resonance Imaging and Surgical Findings

PURPOSEnSome groups consider magnetic resonance imaging the gold standard to diagnose urethral diverticula with up to 100% reported sensitivity. We describe cases contradicting this paradigm and identify reasons for discrepancies.nnnMATERIALS AND METHODSnWe searched a database for women who underwent urethral diverticulum surgery from 1998 to 2008 and also underwent preoperative magnetic resonance imaging. Images were reviewed by a blinded panel of urologists and a radiologist. They came to consensus on the presence or absence, site and anatomy of urethral diverticulum or cancer, and compared operative findings. Discrepancies were classified as errors in urethral diverticulum or cancer diagnosis and errors in urethral diverticulum anatomy or site.nnnRESULTSnOf 76 patients who underwent diverticulectomy 41 also underwent magnetic resonance imaging, of whom 10 (24.4%) had a discrepancy between magnetic resonance imaging and surgical findings. In 6 of these cases there were diagnosis errors and diverticula were not seen on magnetic resonance imaging in 3. One urethral diverticulum each was misdiagnosed as Bartholins cyst and as a typical post-collagen injection appearance. A sterile abscess was incorrectly diagnosed as a urethral diverticulum. In 2 patients magnetic resonance imaging did not detect cancer within the diverticulum. A major discrepancy in anatomy made intraoperative decision making difficult in 2 patients.nnnCONCLUSIONSnIn cases clinically suspicious for urethral diverticulum magnetic resonance imaging had a 24.4% error rate. Serious consequences are failure to detect cancer and suboptimal treatment for urethral diverticulum. The reason for the high magnetic resonance imaging accuracy rate in other series may be that in the absence of radiological confirmation some surgeons may choose not to perform surgery. Magnetic resonance imaging is useful to assess urethral diverticula but physicians should be aware of its limitations.

Salvage Surgery after Failed Treatment of Synthetic Mesh Sling Complications

PURPOSEnWe report our experience with the diagnosis and treatment of refractory synthetic sling complications in women.nnnMATERIALS AND METHODSnThis is a retrospective study of consecutive women with failed treatments for mesh sling complications. Before and after surgery the patients completed validated questionnaires and voiding diaries, and underwent uroflow with post-void residuals, pad test, cystourethroscopy and videourodynamic studies. Treatment was individualized, and results were subdivided into the 2 groups of conditions and symptoms. Outcomes were assessed with the Patient Global Impression of Improvement with success classified as a score of 1, improvement as 2 to 3 and failure as 4 to 7.nnnRESULTSnA total of 47 women 35 to 83 years old (mean 60) had undergone at least 1 prior operation (range 1 to 4) to correct sling complications. Original sling composition was type 1 mesh in 36 patients and types 2 and 3 in 11. Surgical procedures included sling incision, sling excision, urethrolysis, urethral reconstruction, ureteroneocystotomy, cystectomy and urinary diversion, and enterocystoplasty. Median followup was 2 years (range 0.25 to 12, mean 3). Overall a successful outcome was achieved in 34 of 47 patients (72%) after the first salvage surgery. Reasons for failure were multiple for each patient. Of the 13 patients with treatment failure 9 subsequently underwent 14 operations. Success/improvement was achieved in 5 women (56%) after continent urinary diversion (1), continent urinary diversion and cystectomy (1), partial cystectomy and augmentation cystoplasty (1), biological sling and sinus tract excision (1), and vaginal mesh excision (1).nnnCONCLUSIONSnSuccess after the initial failure of mesh sling complications repair is possible but multiple surgeries may be required. Each symptom should be addressed separately.

A Review of Lower Urinary Tract Symptoms in Patients with Parkinson’s Disease

To critically review recent literature on lower urinary tract symptoms (LUTS) in patients with Parkinson’s Disease.A literature search was conducted using the keywords LUTS, urinary symptoms, non-motor, and Parkinson’s disease (PD) via the PubMed/Medline search engine. In the literature, we critically examined lower urinary symptoms in Parkinson’s patients by analyzing prevalence, pathogenesis, urinary manifestations, pharmacologic trials and interventions, and prior review articles. The data collected ranged from 1986 to the present with an emphasis placed on recent publications.The literature regards LUTS in PD as a major comorbidity, especially with respect to a patient’s quality of life. Parkinson’s patients experience both storage and voiding difficulties. Storage symptoms, specifically overactive bladder, are markedly worse in patients with PD than in the general population. Surgical management of prostatic obstruction in PD can improve urinary symptoms. Multiple management options exist to alleviate storage LUTS in patients with PD, ranging from behavioral modification to surgery, and vary in efficacy.Lower urinary tract dysfunction in PD may be debilitating. Quality of life can be improved with a multi-pronged diagnosis-specific approach to treatment that takes into consideration a patient’s ability to comply with treatment. A stepwise algorithm is presented and may be utilized by clinicians in managing LUTS in Parkinson’s patients.

The Pathophysiology of Large Capacity Bladder

PURPOSEnWe describe the pathophysiology, differential diagnosis and urodynamic findings in patients with a large capacity bladder.nnnMATERIALS AND METHODSnThis was a retrospective, observational study of 100 consecutive patients with voiding dysfunction and a cystometric bladder capacity of greater than 700 ml. Clinical data, cystometric bladder capacity and other urodynamic findings were evaluated. Bladder outlet obstruction and impaired detrusor contractility were defined by the Schaefer nomogram in men and the Blaivas-Groutz nomogram in women.nnnRESULTSnA total of 56 men and 44 women 36 to 97 years old (median age 75, mean 71.2) with a bladder capacity of 700 to 5,013 ml (median 931, mean 1,091) were studied. The primary pathophysiological diagnoses were bladder outlet obstruction in 48% of cases, impaired detrusor contractility in 11%, absent detrusor contractility in 24% and normal detrusor pressure/uroflow study in 17%. Bladder outlet obstruction was attributable to anatomical obstruction in 34% of patients, acquired voiding dysfunction in 11% and detrusor-external sphincter dyssynergia in 3%. In patients with detrusor contractions the initial contraction occurred at a median of 1,000 ml (mean 1,154, range 86 to 5,000). Associated diagnoses in men included benign prostatic enlargement in 52% and neurological disease in 14%, and in women they were pelvic organ prolapse in 27%, stress incontinence in 18% and neurological disorders in 9%.nnnCONCLUSIONSnThe etiology of large capacity bladder is multifactorial and often a potentially remediable underlying condition exists. A large capacity bladder may be accompanied by bladder outlet obstruction, impaired or absent detrusor contractions, or normal detrusor pressure/uroflow studies. When detrusor contractions are present, they usually occur only at large bladder volumes. Therefore, it is important during cystometry to fill the bladder until capacity is achieved.

Urethroplasty Improves Overactive Bladder Symptoms in Men With Anterior Urethral Strictures.

OBJECTIVEnTo assess the effect of urethroplasty on overactive bladder (OAB) symptoms.nnnMATERIALS AND METHODSnFrom March 2011 to November 2014, 47 anterior urethroplasties were performed by a single surgeon (RSP). Of these, 42 men prospectively completed the validated Overactive Bladder Symptom Score (OABSS) prior to and after urethroplasty. Comparative analysis of preoperative to postoperative OABSS results was performed.nnnRESULTSnThe median (range) age of men who comprised our cohort was 49 (22-90). Questionnaires were completed preoperatively and at a median of 12 months (2.3-74.6) postoperatively. Stricture location included the following: bulbar (75%), penile (15%), and membranous (7.5%) urethra. Median stricture length was 3u2009cm (1-6). Half of the men underwent an excision and anastomotic repair, and half underwent buccal mucosal graft. Men experienced significant improvement in urinary flow rate, postvoid residual urine, and OAB symptoms reported on the OABSS. Of the 28/42 men with preoperative, clinically significant OAB (ie, OABSSu2009≥u20098), 25/28 reported a 54.2% (0%-100%) median reduction in OABSS, with only 1 patient reporting worsening of symptoms following surgery. Those men with the highest preoperative OABSS experienced the greatest improvement in OAB symptoms postoperatively.nnnCONCLUSIONnIn men with anterior urethral strictures and OAB, urethroplasty decreased reported OABSS byu2009>50% and cured 90% of men with clinically significant OAB symptoms.

A New Staging System for Anterior Urethral Strictures

Introduction: Currently there is no widely accepted staging system for anterior urethral strictures. We developed and evaluated the reliability of an easy to use classification system for anterior urethral strictures in men. Methods: We devised a staging system based on cystoscopic findings of no stricture (stage 0), wide caliber stricture (stage 1), stricture requires gentle dilation with a 16Fr flexible cystoscope (stage 2), stricture cannot be dilated (stage 3) and no visible lumen (stage 4). Content validity was established by a panel of 5 urologists. On 2 separate occasions 3 urologists independently viewed videos obtained during cystoscopy and staged the tightest visible stricture. If multiple strictures were present, the stricture with the smallest visible lumen was used for the purpose of this study. All men who had undergone cystoscopy at our institution between 2011 and 2012 were included in the study. Exclusion criteria were poor video quality and not visualizing the entire urethra during cystoscopy. Results: A total of 101 videos of consecutive cystoscopies were reviewed. Intra‐observer agreement was 76% to 94% (Cohen &kgr; 0.65–0.90) and interobserver agreement was 73% to 82% (Cohen &kgr; 0.51–1.00, 0.69 overall, p <0.001). The intra‐observer and interobserver agreement increased for each stage, with 3 and 4 almost unanimously identified by all 3 observers (Cohen &kgr; 0.93 and 1.00, p <0.001). Conclusions: This new staging system is simple and easy to use, and has excellent intra‐observer and good interobserver reliability. The staging system provides a simple lexicon for describing the appearance of anterior urethral strictures.

Mesh Infection of a Male Sling

A 52-year-old man presented with purulent drainage from the scrotum and medial superior left thigh approximately 5 months after a second surgical procedure to remove fragments of an AdVanceTM male sling from the left thigh. Medical history began 6 years earlier when he underwent robot-assisted laparoscopic prostatectomy for high grade prostate cancer. One year postoperatively he was treated with adjuvant intensity modulated radiation and hormonal therapy for biochemical recurrence. Two years later he underwent the first AdVance sling placement for sphincteric incontinence refractory to conservative measures, and the next year he underwent a second AdVance sling placement for recurrent incontinence. Shortly after the second AdVance sling placement, the patient reported perineal pain as well as purulent drainage from the left thigh. Excision of purulent peri-urethral segments of 2 AdVance male slings and part of the segment of the sling in the left thigh were excised. A second surgery was performed to remove a fragment of the sling in the left thigh because of recurrent drainage. Cystoscopy showed no erosion of the sling into the urinary tract. Magnetic resonance imaging (MRI), the best study to identify sinus tracts, fistulas and abscesses in the perineum or proximal thigh, revealed a 3 cm abscess in the gracilis muscle of the

Female Urethral Reconstructive Surgery

Female urethral reconstruction is an uncommonly performed surgery to repair female urethral strictures, diverticulum, and fistulas. Because of the rarity of these operations, complications have not been well described in the literature. Complications can be categorized as intraoperative and postoperative. Postoperative can be further divided into general complications common to all pelvic surgery, which will not be discussed here, and those that are specific to urethral reconstruction. Those complications include: (1) early or late postoperative wound complications from the graft or flap harvest site, (2) stricture or fistula recurrence, (3) de novo postoperative incontinence, (4) de novo or recurrent urethral obstruction, and (5) de novo detrusor overactivity.

Transvaginal Urethrolysis for Urethral Obstruction

Bladder outlet obstruction (BOO) in women is rare with an incidence ranging from 2.7 % to 8.3 %. Presentation is variable but may include both storage and voiding symptoms. Consequently, diagnosis can be challenging and may require pressure-flow studies (PFS), video urodynamics, voiding nomograms, or a combination of these techniques. The etiology of female BOO can be anatomic or functional with iatrogenic obstruction following anti-incontinence surgery the most common cause. The two basic approaches used to correct urethral obstruction are sling incision/excision and urethrolysis (retropubic, transvaginal, or suprameatal). Success rates for formal urethrolysis range from 43 % to 94 % and 80 % to 100 % for sling incision. Complications following procedures to relieve obstruction include recurrent stress incontinence and overactive bladder symptoms. Given the complexity of these cases, patients should be closely monitored for symptom resolution.

Treatment of Overactive Bladder Refractory to Medications

Conservative therapy for overactive bladder (OAB) has been shown to be a viable stand alone or adjunctive option to antimuscarinic agents (AMAs). Typically nonsurgical options such as behavioral therapy, pelvic floor muscle therapy (PFMT), and biofeedback have been recommended prior to more invasive options such as electrical stimulation, intravesical Botox, or augmentation enterocystoplasty, ileovesicostomy, and urinary diversion. We believe this standard step-wise algorithmic approach to treatment is reasonable, but in some instances may subject patients to unnecessary expense and delay in treatment. Rather, we prefer to individualize our approach to maximize the likelihood of success in each patient while appropriately weighing relative risks with potential benefits. So, for example, a patient with severe neurogenic OAB refractory to AMA may opt for augmentation cystoplasty rather than intradetrusor injection of Botox or neuromodulation.