Sherif R. Aboseif

EFFECT OF SILDENAFIL CITRATE ON POST-RADICAL PROSTATECTOMY ERECTILE DYSFUNCTION

PURPOSE We assess the effect of sildenafil in a subgroup of patients after prostatectomy with erectile dysfunction and determine whether nerve preservation improves sildenafil response in this subgroup. MATERIALS AND METHODS Between April 1998 and January 1999, 53 patients who had undergone radical retropubic prostatectomy and were prescribed oral sildenafil were surveyed using a confidential mail questionnaire. Of the patients 21 underwent bilateral and 15 unilateral neurovascular bundle sparing procedures, while in 17 a nonnerve sparing procedure was performed. All patients received 25 to 100 mg. sildenafil in a flexible dose escalation manner. Response, satisfaction and side effects were assessed using a modified, self-administered International Index of Erectile Function questionnaire. Response was defined as erection sufficient for intercourse. Preoperative and postoperative/pretreatment erectile functions were assessed for baseline comparison in each patient, and partner overall satisfaction with sildenafil was measured. Statistical data analysis was performed using analysis of variance and Newman-Keuls multiple comparison tests. RESULTS Of the 21 patients who underwent a bilateral nerve sparing procedure 15 had a positive response. Of the 15 patients who had undergone a unilateral nerve sparing procedure 12 had a positive response, and only 1 of the 17 patients who had undergone a nonnerve sparing procedure responded to sildenafil. The most commonly reported adverse events of all causes were headaches (21%), flushing (8.3%), visual disturbance (6.3%) and nasal congestion (6.3%). CONCLUSIONS Sildenafil is an equally effective treatment for erectile dysfunction after bilateral and unilateral nerve sparing procedures, and patient response to sildenafil is confirmed by the partners. However, patients who undergo nonnerve sparing procedures do not respond satisfactorily to sildenafil.

The Adjustable Continence Therapy System for Recurrent Female Stress Urinary Incontinence: 1-Year Results of the North America Clinical Study Group

PURPOSE We determined the efficacy, safety, adjustability and technical feasibility of the adjustable continence therapy device (Uromedica, Plymouth, Minnesota) for the treatment of recurrent female stress urinary incontinence. MATERIALS AND METHODS Female patients with recurrent stress urinary incontinence were enrolled in the study and a defined set of exclusionary criteria were followed. Baseline and regular followup tests to determine eligibility, and to measure subjective and objective improvement were performed. A trocar was passed fluoroscopically and with digital vaginal guidance to the urethrovesical junction through small incisions between the labia majora and minora. The adjustable continence therapy device was delivered and the balloons were filled with isotonic contrast. The injection ports for balloon inflation were placed in a subcutaneous pocket in each labia majora. Device adjustments were performed percutaneously in the clinic postoperatively. An approved investigational device exemption Food and Drug Administration protocol was followed to record all adverse events. RESULTS A total of 162 subjects underwent implantation with 1 year of data available on 140. Mean Stamey score improved by 1 grade or more in 76.4% (107 of 140) of subjects. Improvement in the mean incontinence quality of life questionnaire score was noted at 36.5 to 70.7 (p <0.001). Reductions in mean Urogenital Distress Inventory (60.3 to 33.4) and Incontinence Impact Questionnaire (54.4 to 23.4) scores also occurred (p <0.001). Mean provocative pad weight decreased from 49.6 to 11.2 gm (p <0.001). Of the patients 52% (67 of 130) were dry at 1 year (less than 2 gm on provocative pad weight testing) and 80% (102 of 126) were improved (greater than 50% reduction on provocative pad weight testing). Complications occurred in 24.4% (38 of 156) of patients. Explantation was required in 18.3% (28 of 153) of the patients during 1 year. In terms of the complications 96.0% were considered to be mild or moderate. CONCLUSIONS The Uromedica adjustable continence therapy device is an effective, simple, safe and minimally invasive treatment for recurrent female stress urinary incontinence. It can be easily adjusted percutaneously to enhance efficacy and complications are usually easily manageable. Explantation does not preclude later repeat implantation.

Corporeal plication for the treatment of congenital penile curvature.

PURPOSE We evaluated the long-term outcome, effectiveness and patient satisfaction of corporeal plication for the correction of congenital penile curvature. MATERIALS AND METHODS A total of 25 patients with congenital penile curvature were included in the study. Mean age was 39 years (range 15 to 45). Patients with Peyronies disease, and/or chordee associated with hypospadias or evidence of erectile dysfunction were excluded from analysis. All procedures were done on an outpatient basis using local anesthesia. The technique of corporeal plication consists of placing longitudinal plication sutures of 2-zero braided polyester on the opposing side of curvature until it is corrected during artificially induced erection. A standardized questionnaire was then completed via telephone interview to assess results as well as the patient satisfaction rate. RESULTS A total of 22 patients were available for evaluation. Successful results at up to 3(1/2) years (range 1 to 42 months, mean 18) of followup were achieved in 21 of the 22 patients (95%). Success was defined as the correction of curvature and a patient satisfaction rate of 75% or greater. Curvature was ventral in 20 cases, dorsal in 2 and left lateral in 3. Shortening of the penis after surgery was noted by 4 patients (18%), of whom 3 nevertheless had a satisfaction rate of 75% or greater. In 2 patients postoperative hematoma resolved spontaneously. Mean operative time was 50 minutes and 22 of the 25 patients (88%) received local anesthesia. CONCLUSIONS Corporeal plication is a simple, minimally invasive surgical procedure that proved to be effective for congenital curvature of the penis compared with other, more extensive penile reconstruction surgery.

PERCUTANEOUS NEEDLE BLADDER NECK SUSPENSION FOR THE TREATMENT OF STRESS URINARY INCONTINENCE IN WOMEN: LONG-TERM RESULTS

PURPOSE We evaluated the long-term results of percutaneous needle suspension using bone anchor devices for treating stress urinary incontinence in women. MATERIALS AND METHODS We retrospectively evaluated the long-term results of percutaneous bladder neck needle suspension performed at our institution. None of the women had undergone any anti-incontinence surgery before percutaneous needle suspension. A telephone survey was done for all available patients. Subjective cure was defined as no evidence of incontinence, significant improvement as 0 to 1 protective pad soaked daily and patient satisfaction with incontinence level, and failure as more than 1 pad used daily, lack of patient satisfaction or a secondary procedure required to treat stress urinary incontinence. In cases considered failures a detailed video urodynamic study was performed when possible before any secondary procedure. RESULTS In 1996 and 1997, 49 patients underwent percutaneous needle bladder neck suspension with bone anchors, of whom 42 (86%) were available for telephone interview. Mean patient age was 57 years (range 31 to 77) and mean followup was 29 months (range 16 to 52). As defined, subjective outcome in the 42 women was cure in 2 (5%), significant improvement in 5 (12%) and failure in 35 (83%). Of the 35 patients with treatment failure who did not undergo a secondary procedure 25 were asked to present for video urodynamics and 18 were evaluated. Urodynamics revealed demonstrable urinary incontinence, urethral hypermobility in 16 (88%), intrinsic sphincter deficiency in 1 (6%) and detrusor instability in 1 (6%). In 2 cases x-ray revealed that a bone anchor had dislodged and migrated into the pelvis. Serious osteomyelitis at the bone anchor site in 1 case required surgical débridement and 6 weeks of intravenous antibiotics. CONCLUSIONS Percutaneous needle suspension is associated with poor long-term results in women with stress urinary incontinence. Other procedures should be considered.

Review of Intentionally Self-Inflicted, Accidental and Iatrogetic Foreign Objects in the Genitourinary Tract

Purpose: Retrospective evaluation of a series of patients presenting with genitourinary foreign objects. Patients and Methods: From 1997 to 2007, 11 men and 2 women were treated for a variety of foreign objects in the genitourinary tract. Medical records were reviewed for presentation, diagnosis, mental status, drug dependency, treatment, and follow-up. Results: 13 patients were seen for removal of the foreign objects or for treatment of the sequela. These objects were intentionally self-inflicted, accidentally introduced or iatrogenic in nature. Intentional objects included: safety pins, screwdriver, marbles, pen cap, pencils, straw, cocaine, stiff metal wire and part of a pizza mixer. Accidental objects included: magnets, female catheter, urinary incontinence devices and part of a Foley catheter. The iatrogenic object was a reservoir from an inflatable penile implant. Smaller noninjurious objects were retrieved cystoscopically or at the bedside; larger objects or objects associated with trauma to the urethra needed open and reconstructive operations. Conclusions: Generally thought to be self-inflicted for personal gratification, the source of genitourinary objects can also be accidental or iatrogenic. The most traumatic injuries are purposely self-inflicted and found in patients who remove the objects themselves. These patients are at higher risk of permanent urethral damage needing complex surgical treatment and follow-up.

Repair of Giant Vesicovaginal Fistulas

PURPOSE We evaluated the long-term success rate of an abdominovaginal approach using a rotational bladder flap to repair giant vesicovaginal fistula. MATERIALS AND METHODS A total of 35 patients were included in this study. Of these patients 28 had a large vesicovaginal fistula and 7 had complete loss of the urethral floor. Fistula etiology was secondary to obstructed labor in 25 patients, the result of iatrogenic surgical injuries in 5, sling erosion in 3 and pelvic irradiation in 2. Using combined abdominal and vaginal approaches the bladder was bisected sagittally, and a bladder flap was rotated downward and medially to fill the extensive fistula defect. An additional vascularized flap was interposed in 23 patients including gracilis muscle flap in 13, omental flap in 5, peritoneal flap in 2 and Martius flap in 3. RESULTS Fistulas were successfully repaired in 31 of 35 patients (88%). The remaining 4 patients underwent surgical correction with a second, more limited repair. This group included 2 patients with fistula from obstructed labor, 1 due to sling erosion and 1 due to irradiation. CONCLUSIONS A combined abdominovaginal approach with the use of a generous rotational bladder flap for repair of a complex vesicovaginal fistula allowed for excellent results. There was a high success rate on the first attempt due to the excellent exposure and healthy, well vascularized tissue used for repair.

Overactive bladder: drug therapy versus nerve stimulation

Overactive bladder is a common urologic disorder with a number of etiologies and evolving treatment options. The two primary management strategies are drug therapy and sacral neurostimulation, both areas of recent developments with the emergence of new medications and refinement of surgical techniques. In this Viewpoint, Apurba Pathak and Sherif Aboseif discuss the relative merits, and drawbacks, of these very different approaches.

Surgical treatment for stress urinary incontinence with urethral hypermobility: what is the best approach?

Abstract. A comparative study evaluating the results of three surgical procedures for stress urinary incontinence (SUI) with urethral hypermobility. This is a retrospective study of 189 patients, evaluating the outcomes of the percutaneous needle suspension using bone anchors (PNS), abdominal suspension (AS), and pubovaginal sling (PVS). The mean follow-up was 30.5 months. In our results, the patients were divided into three groups: PNS (49), AS (34), and PVS (106). No differences were found preoperatively. Intraoperatively, PNS had the shortest operative time and lowest estimated blood loss, and it is the only outpatient procedure. However, it had the highest complication rate. PNS had the lowest satisfactory rate (16.7%). This was followed by AS (78%), PVS with cadaveric fascia (90%), and PVS with autologous fascia (94%). In conclusion, PNS is a simple outpatient procedure, but the long-term results are disappointing. Both AS and PVS gave good results. PVS was superior to AS in shorter hospitalization, early recovery and overall patient satisfaction.

Four-year follow-up on 68 patients with a new post-operatively adjustable long-term implant for post-prostatectomy stress incontinence: ProACT™

This paper presents 4‐year follow‐up results for patients enrolled in a pivotal study conducted to support an FDA premarket approval application (PMAA). The study evaluated the safety and efficacy of the ProACT Adjustable Continence Therapy for the treatment of post‐prostatectomy stress urinary incontinence (SUI).

Treatment with an adjustable long-term implant for post-prostatectomy stress incontinence: The ProACT™ pivotal trial

This paper presents 18‐month follow‐up results for patients enrolled in a pivotal study conducted to support an FDA premarket approval application (PMAA). The trial evaluated the safety and efficacy of the ProACT Adjustable Continence Therapy for the treatment of post‐prostatectomy stress urinary incontinence (SUI).