Robert H. Hackler

Bladder Hypocompliance in the Spinal Cord Injury Population

To determine the incidence and effects of low bladder compliance on the upper urinary tracts in spinal cord injury patients, we evaluated the last 254 patients during a 3-year period who underwent a complete urodynamic study, along with an excretory urogram and/or renal ultrasound. Compliance was determined at 100 cc volume. A compliance number of 20 or less was considered low. Of the 254 patients 43 (17 per cent) had low compliant bladders by our definition. Hydronephrosis was present in 56 of the 84 renal units (64 per cent) and reflux was present in 39 (46 per cent). These results are in sharp contrast to the normal compliant group in which 21 per cent of 418 renal units had hydronephrosis and only 6 per cent had reflux. Of the 254 patients over-all 44 had lower motor neuron lesions as determined by no bulbocavernosus reflex as well as a denervated external sphincter; 22 of these 44 patients (50 per cent) had low compliant bladders. Conversely, among the 210 patients with suprasacral lesions only 21 (10 per cent) had low compliant bladders. In conclusion, the development of a low compliant bladder in spinal cord injury patients is not an uncommon event and places the upper urinary tracts at great risk. All attempts must be directed toward maintaining low detrusor pressures, and these patients must have adequate and frequent followup evaluation.

Complications of Penile Prostheses in the Spinal Cord Injury Population

A total of 63 spinal cord injury patients underwent penile implantation. Followup ranged from 6 months to 11 years (average 41 months). A semirigid device was used in 53 patients with complications dictating loss of the prosthesis in 17 (33 per cent). The most common complication was spontaneous erosion and most of these occurred after 6 months. Of the 17 patients 8 underwent reimplantation with loss of the prosthesis in 3. Ten patients received an inflatable penile prosthesis and 4 of these were lost. Of the 4 uninfected patients 2 underwent successful reimplantation. Overall, the complication rate in the 63 patients was 33 per cent. After reimplantation 52 of the 63 patients have a functional device, resulting in an ultimate success rate of 82 per cent. In conclusion, penile prostheses have greatly benefited spinal cord injury patients with problems such as sexual dysfunction, maintenance of external appliances and decreasing the rate of skin lacerations. However, these benefits must be weighed against a significant complication rate.

SPINAL CORD INJURIES Urologic Care

Abstract In recent years the survival rate in the patient with spinal cord injury is improving. Renal failure remains the principal cause of death if the patient has a poor (unbalanced) bladder. In the good reflex bladder group, just as many succumb from nonrenal causes. In most of the patients with upper motor neuron lesions, a reflex bladder develops, and with the use of intermittent catherization, external sphincterotomy, and sacral rhizotomy the bladder should remain catheter free. Irreversible vesicoureteral ref ex subjects some patients to Foley catheter drainage. Vesicoureteroplasty is indicated if the patient has a good reflex bladder. Transureteroureterostomy has its place in failed vesicoureteroplasty. Under certain conditions, an ileal conduit is definitely of benefit. We are conservative in recommending an ileal conduit, since deterioration of many renal units can be reversed by treatment directed toward the bladder. Severe hydronephrosis is best handled with loop nephrostomies.

Closure of the bladder Neck in Spinal Cord Injury Patients with Urethral Sphincteric Incompetence and Irreparable Urethral Pathological Conditions

Total urinary incontinence developed secondary to incompetence of the urethral closing mechanism in 8 spinal cord injury patients who were on Foley catheter drainage (5 patients) or suprapubic cystostomy (3 patients). All patients had irreparable urethrocutaneous fistulas and 4 had urethroperineal erosion. Closure of the bladder neck with drainage via a suprapubic cystostomy tube was used to divert the urinary stream. Bladder neck closure was successful in alleviating total urethral urinary incontinence in all patients. However, suprapubic abdominal leakage developed in 2 patients. This procedure should be recommended cautiously when a maximal bladder capacity greater than 125 cc cannot be maintained unless concomitant augmentation cystoplasty also is considered.

Infected Suture Granuloma Simulating Mass of Urachal Origin: Case Report

We report a case of an infected suture granuloma. The patient presented with a solid mass located superior to the dome of the bladder. Evaluation showed a normal intestinal tract and absence of a primary bladder abnormality. Based on these findings the mass was considered to be of urachal origin but surgical excision revealed that the mass was an infected suture granuloma. Suture granuloma should be considered in patients who have had previous inguinal surgery, particularly when associated with the use of nonabsorbable suture.

Mentor inflatable penile prosthesis: A reliable mechanical device

Forty-six patients have undergone implantation of a penile prosthesis using the Mentor inflatable device. All patients are at least six months postimplantation, with the average follow-up being twenty-one months. Six patients have required reoperation due to technical problems, but there have been no mechanical failures. This low mechanical failure rate greatly enhances the attractiveness of this type of penile prosthesis when comparing it with the semirigid devices.

Simplified coagulum pyelolithotomy using cryoprecipitate.

Coagulum pyelolithotomy has been beneficial in removing calyceal calculi when the diameter of the infundibulum and pelvis is adequate. By utilizing a simple, precise ratio of cryoprecipitate, thrombin, and calcium chloride (25:4:1), an effective coagulum was obtained in 7 consecutive cases with complete stone removal in 5.

Urethral complications following ischiectomy in spinal cord injury patients: a urethral pressure study.

Ischial ulcers are the most common pressure sores in spinal cord injury patients and ischiectomy often is used in the over-all management. Because a high percentage of spinal cord injury patients with total ischiectomy had complications of the membranous and proximal bulbous urethra, we evaluated urodynamically 15 ischiectomy patients in the supine and sitting positions to determine if pressure usually borne by the ischial tuberosities was transmitted to the membranous and proximal bulbous urethra. Of the 8 patients with a complete ischiectomy at least on 1 side 5 had problems of the membranous and proximal bulbous urethra, and the average urethral pressure increase from the reclining to the sitting position was 111 cm. water. The increase in urethral pressure was not related to any change in bladder or abdominal pressure. The average urethral pressure increase in the nonischiectomy patients was only 16 cm. water and none had any problems of the membranous and proximal bulbous urethra. Some retrospective clinical studies have implicated ischiectomy in the development of these urethral complications. Our urodynamic data lend some direct evidence that a more complete ischiectomy results in excessive urethral pressure with the patient in the sitting position, thereby predisposing the membranous and proximal bulbous urethra to problems related to ischemia. Five of the 8 patients with more complete ischiectomy and 1 with bilateral partial ischiectomy had high urethral pressures and complications, such as pseudodiverticulum, diverticulum and dilatation. More incomplete ischiectomy should be used to obviate this urethral damage.

Transureteroureterostomy in Spinal Cord Injury Patients for Persistent Vesicoureteral Reflux: 6 To 14-Year Followup

We did a long-term followup for spinal cord injury patients who had undergone transureteroureterostomy for persistent reflux after failed vesicoureteroplasty. Particular attention was paid to the complications that are unique to these patients and include the trapping of ureteral calculi, recurrent vesicoureteral reflux and bladder hypertrophy with vesicoureteral junction obstruction. Caution is advised in using this procedure in the spinal cord injury patient because of these problems despite the over-all success in maintaining the patency of the anastomosis.

Evaluation and management of early stages of carcinoma of prostate.

Abstract If the current treatment modalities are to be used effectively in the management of prostatic cancer, the clinician must be aware of the anatomic extent of the disease prior to initiating therapy. The use of the A, B, C, D staging classification is no longer adequate. Because of the growth characteristics and varying metastatic potential, the staging classification should be subdivided. Also clinical staging of the tumor by use of digital rectal examination, transurethral resection tissue examination, and routine x-ray examination findings are not reliable and are associated frequently with understaging of the actual extent of tumor. While therapeutic benefits of bilateral pelvic lymph node dissection remain controversial, the diagnostic importance is clearly recognized in the early stages of prostatic cancer. Clinical Stage A 1 adenocarcinoma is unlikely to have either lymph node or capsular extension, but this is not true with higher stage malignancies. It is therefore imperative that Stage A 2 through Stage B 2 tumors have pathologic examinations of the pelvic lymph nodes. In general, the higher the clinical stage, the more likely tumor positive lymph nodes will be found. Similarly, it is important to distinguish the high-grade tumor from the low-grade malignancies since less differentiated cancers are associated more frequently with tumor extension to the lymph nodes. Evaluation of past experience in the treatment of localized prostatic carcinoma is difficult since most studies are not randomized; prospective double blind and long-term survival figures are based on inaccurate clinical staging. The time-honored radical surgery using either perineal or retropubic total prostatectomy is appealing since the objective is removal of all malignant tissue. This surgery remains the standard by which all other treatments are compared. For those clinicians who would prefer one of the less invasive techniques, one can find support for either the external beam radiotherapy or the use of interstitial radioactive sources. The early results of radiotherapy are encouraging despite the appearance of recognizable malignant cells in follow-up biopsy specimens. Whether or not the radiotherapy measures up to or exceeds that of radical surgery, can be judged only when long-term survival statistics based on anatomic staging and careful grading are known.