Roger Dmochowski

Experience with the Management of Urethral Diverticulum in 63 Women

The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.

Primary Bladder Neck Obstruction: Urodynamic Findings and Treatment Results in 36 Men

PURPOSE We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction. MATERIALS AND METHODS A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases. RESULTS Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30% of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision. CONCLUSIONS Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.

Peyronie's Disease: Surgical Treatment Based on Penile Rigidity

Operative treatment of Peyronies disease has the risk of penile shortening and/or loss of erection. To avoid these complications, we used plaque incision together with polytetrafluoroethylene (Gore-Tex) graft insertion in men with preserved penile rigidity and only implanted a penile prosthesis in men with erectile failure. Between August 1986 and July 1992, 24 men 36 to 72 years old (mean age 53 years) underwent surgery. Of the men 16 with adequate penile rigidity by history and/or RigiScan study, and severe curvature underwent plaque incision and polytetrafluoroethylene graft insertion. Eight men had erectile failure, including 4 with distal flaccidity as demonstrated by RigiScan study. These 8 men received a penile prosthesis (semirigid in 6 and inflatable in 2). In addition, 2 of these men also required plaque incision because of persistent curvature. With a mean followup of 47 months (range 20 to 92), all 16 men with incision and a polytetrafluoroethylene graft had excellent erections with satisfactory intercourse. Minimal curvature away from the plaque incision site, not causing any difficulty with sexual performance, occurred in 7 patients. The men with a penile prosthesis engage in normal intercourse without residual or recurrent curvature. Incision of Peyronies plaque and polytetrafluoroethylene graft insertion is associated with an excellent functional result in men with normal preoperative penile rigidity. A penile prosthesis should be reserved for men with erectile failure.