Shahar Madjar

BONE ANCHORED SLING FOR THE TREATMENT OF POST-PROSTATECTOMY INCONTINENCE

PURPOSE This ongoing study evaluates the safety and efficacy of a new minimally invasive sling procedure for treating post-prostatectomy incontinence. MATERIALS AND METHODS A total of 16 men 56 to 74 years old (mean age 67) underwent the procedure using the Straight-In bone anchoring system. Time after prostatectomy was 1.5 to 5 years (mean 2.5). Of the 16 patients 14 had urodynamically confirmed stress urinary incontinence, while 2 had mixed incontinence with stress incontinence and detrusor instability. The procedure is performed with the patient in the lithotomy position using a perineal approach. Four miniature bone screws with pre-attached pairs of No. 1 polypropylene sutures are placed directly into the medial aspect of the inferior rami of the pubic bone. A pair of bone anchors is placed just below the symphysis on each side, and the second pair is inserted 3 to 4 cm. lower. To support the bulbar urethra a gelatin coated polyethylene terephthalate trapezoid shaped sling or cadaveric fascia lata is tied to the pubic bone using the 4 pairs of sutures attached to the bone anchors. Urethral resistance is increased to 30 to 50 cm. water above baseline pressure. RESULTS Followup was 4 to 20 months (mean 12.2). Of the 14 men with the preoperative urodynamic diagnosis of genuine stress incontinence 12 were cured of incontinence, defined as subjectively dry with no or only 1 pad used daily for security without any episode of leakage, while 2 were improved subjectively with a decrease of 50% or more in pads daily. Two other patients with the preoperative diagnosis of mixed urinary incontinence were improved. Postoperatively urodynamic study in these patients revealed resolved stress incontinence but persistent urge urinary incontinence. They responded to anticholinergics and are completely dry. Intraoperative and postoperative complications were minimal with no erosion, infection or osseous complications. CONCLUSIONS This new minimally invasive male sling procedure is safe and efficacious. Adjusting sling tension by measuring urethral resistance results in a low rate of over correction and failure. Further experience is needed to establish this procedure as treatment for post-prostatectomy incontinence.

Clinical Significance of Tumor Angiogenesis in Patients with Localized Renal Cell Carcinoma

OBJECTIVES To determine the relationship between angiogenesis and various histopathologic features as well as clinical outcome in patients with localized renal cell carcinoma (RCC). METHODS Microvessel density was quantified by using immunocytochemical staining of endothelial cells for factor VIII-related antigen of 36 specimens taken from patients with pathologic Stage pT1 or pT2 RCC. All patients underwent radical nephrectomy and were followed for a mean time of 97.3 months. RESULTS No association was noted between microvessel count (MVC) and either cell type, architecture, or tumor size. Inverse correlation was noted between MVC and nuclear area (P = 0.006), nuclear elipticity (P = 0.016), nuclear roughness (P = 0.039), and histologic grade (P = 0.047). Patients having tumors with low MVC had significantly better survival rate compared with those with high MVC neoplasms (P = 0.0014, by Cox proportional hazards method). CONCLUSIONS Despite lack of correlation with known predictors of survival, MVC provides independent prognostic information for patients with localized RCC.

The impact of tumor size on clinical outcome in patients with localized renal cell carcinoma treated by radical nephrectomy

PURPOSE We investigated the influence of tumor size on clinical outcome in patients with localized renal cell carcinoma treated with radical nephrectomy. MATERIALS AND METHODS We reviewed retrospectively the records of 54 patients with pathological T1, T2 renal cell carcinoma for age, sex, histological grade, cell type, architecture, deoxyribonucleic acid ploidy pattern, nuclear morphometry and vimentin expression. Variables found to predict outcome were correlated with tumor size, which was further tested for its prognostic value. RESULTS The best predictors of prognosis were grade, ploidy pattern, nuclear morphometry and vimentin expression. Small (less than 5 cm.) and large (larger than 5 cm.) tumors had similar distribution of prognostic variable subgroups. No differences in progression rate or survival were noted between the tumor size categories. CONCLUSIONS These results suggest that small renal tumors may follow unfavorable courses and require aggressive treatment.

INCISIONLESS PER VAGINAL BONE ANCHOR CYSTOURETHROPEXY FOR THE TREATMENT OF FEMALE STRESS INCONTINENCE: EXPERIENCE WITH THE FIRST 50 PATIENTS

PURPOSE We evaluated the safety and efficacy of a new minimally invasive surgical procedure for the treatment of women with genuine stress urinary incontinence. MATERIALS AND METHODS A total of 50 women (mean age 51 years) was treated for type I or II stress urinary incontinence. A miniature bone anchor and a staple like bone anchor driver were used for fixation of periurethral tissue to the public bone. RESULTS The procedure was successfully performed in all patients without intraoperative bleeding. No significant persistent postoperative pain was noted and only 1 patient had urinary tract infection. Concomitant vaginal hysterectomy, cystocele repair or perineoplasty was performed in 33 cases. At 12-month followup 41 patients (82%) are completely continent, 7 patients (14%) reported more than 50% decrease in pad usage and 2 cases are considered surgical failures. Mean operative time was 28 minutes. CONCLUSIONS Data suggest that our new minimally invasive procedure provides a safe, effective and easy to learn alternative for treatment of women with anatomical stress incontinence.

Case reportUrethral erosion of tension-free vaginal tape

Tension-free vaginal tape (TVT) is gaining popularity as a treatment of choice for women with stress urinary incontinence. It is a minimally invasive procedure with reported short operative and postoperative hospitalization times and low complication rates. We describe urethral erosion of a TVT sling material in a 55-year-old woman who presented with immediate postoperative urinary retention. The sling material was surgically removed and the urethral defect repaired, with the patient continent at the 3-month follow-up visit. A mid-urethral synthetic sling such as the TVT can erode into the urethra.

Numb chin syndrome as the presenting symptom of metastatic prostate carcinoma.

We report a case of the numb chin syndrome as the presenting symptom in a patient with metastatic prostate carcinoma. The numb chin syndrome is characterized by facial numbness along the distribution of the mental branch of the trigeminal nerve. Most cases of this syndrome that are not dental in origin have been associated with diffuse metastatic disease, particularly with underlying lymphoproliferative and breast cancer. Although axial and vertebral bone metastases are common in patients with carcinoma of the prostate, mental nerve involvement is rare. We present a case of the numb chin syndrome as the initial clinical manifestation in a patient with metastatic prostate adenocarcinoma.

Transvaginal bone anchored sling

INTRODUCTION To describe a new technique for the treatment of stress urinary incontinence by the transvaginal creation of a sling anchored to the pubic bone. This technique is minimally invasive and easy to learn, with minimal morbidity and complications. TECHNICAL CONSIDERATIONS Miniature bone screws with No. 1 polypropylene sutures attached to them and a battery-operated screw inserter are used for the fixation of a biocompatible fabric sling to the pubic bone. The procedure is performed transvaginally with no abdominal or suprapubic incisions. One screw is inserted on each side of the urethra into the pubic bone below the bladder neck. A tunnel is made submucosally between these two holes just below the bladder neck, and the sling is passed through it. Using the sutures on each side of the urethra, the sling edges are tied and pulled toward the pubic bone. The openings made in the vaginal mucosa are closed with absorbable sutures. CONCLUSIONS This sling procedure is minimally invasive, safe, and effective. Further experience and longer follow-up are necessary to establish its role in the treatment of women with stress urinary incontinence.

Bladder neck suspension using bone anchors for the treatment of female stress incontinence

A new technique and related devices for the treatment of urinary incontinence in women was developed and tested. The technique involves soft tissue to bone fixation by means of miniature bone anchors and a bone anchor inserter. The novel bone anchors are made of a shape-memory nickel titanium alloy (Nitinol) attached to Polypropylene or Gortex suture. A spring-loaded bone anchor inserter drives the anchors through the vaginal wall to a predetermined depth into the pubic bone medulla regardless of the bones hardness, with no incision or drilling required. The device allows for the performance of a minimally invasive transvaginal bladder neck suspension. The procedure has minimal morbidity and a short learning curve. This technique was evaluated clinically in 15 women with incontinence, with a mean follow-up of 6 months. Good urinary continence was achieved in all patients, with no mechanical failures.

A new intraurethral sphincter prosthesis with a self contained urinary pump

An intraurethral sphincter prosthesis with a self contained urinary pump for the management of atonic bladder in women was developed and tested. The prosthesis is comprised of a short, self retaining silicone catheter in which there is a valve and pump. Available in a range of lengths and diameters according to urethral size, its insertion is similar to that of a urethral catheter. The prosthesis is secured by a novel fixation method that has soft expandable silicone fins at the bladder neck and a flexible flange at the external meatus. It is activated by a small hand-held control device. To urinate, the activator is placed on the lower abdomen area and the “on” button is pressed, providing energy to the pump by a magnetic coupling method. Once activated, the valve opens and the pump rotates at a high speed, drawing urine from the bladder and pushing it forward, allowing the patient to “void” with a urine flow of 10 to 12 cc/sec. When the bladder is completely evacuated, the pumping ceases and the valve closes, restoring continence. The device was evaluated clinically in 17 women. Fifteen of the patients had a range of use of 2 weeks to 16 months during which they were dry and had complete bladder emptying. Two patients did not tolerate the device because of uninhibited detrusor contractions and, in both cases, it was removed without complication after 5 days.

A REMOTE CONTROLLED INTRAURETHRAL INSERT FOR ARTIFICIAL VOIDING: A NEW CONCEPT FOR TREATING WOMEN WITH VOIDING DYSFUNCTION

PURPOSE Many patients with voiding dysfunction find clean intermittent catheterization unsatisfactory. We evaluated the efficacy of the new remote controlled intraurethral In-Flow Catheter insert for treating women with voiding dysfunction. MATERIALS AND METHODS We evaluated the efficacy of the intraurethral insert in 92 women with a mean age of 56 years. The insert is available in various sizes to adapt to individual urethras. It comprises a valve and pump assembly. A remote control unit is operated to open the valve and activate the pump, generating active urine flow. RESULTS In 45 patients (49%) the device was removed after a mean of 7.1 days due to local discomfort or urinary leakage around the insert. At a mean followup of 7.6 months (range 2 to 26) 47 women (51%) continued to use the device, and all are dry with complete bladder emptying. The insert was replaced periodically at a mean of 38 days to prevent salt deposits in and around it which lead to urine leakage. Asymptomatic bacteriuria developed in 22 patients (46.8%). Clinical urinary tract infections resolved in 3.9% of all patients-months with oral antibiotics. No dyspareunia was reported. All patients were satisfied with the insert and preferred it to previous treatment modalities. CONCLUSIONS This new remote controlled intraurethral insert is safe and effective in women with voiding difficulties.