Travis L. Bullock

Advances in female stress urinary incontinence: mid-urethral slings.

pessaries, and, in some cases pharmacotherapy. If these measures are not effective, surgery is indicated. Several surgical techniques have been described, with varying success rates, including colposuspension, needle suspensions, anterior vaginal repairs, pubovaginal slings, mid-urethral slings, and injection of bulking agents. Classically the aim of correcting SUI has been to support and/or compress the bladder neck and return it to a more ‘anatomical position’ thus preventing motion, providing a ‘backboard’ for pressure transmission, and compression to compensate for deficient urethral function. However, support without tension or significant compression of the mid-urethra might also increase outlet resistance, preventing dynamic urethral opening, and improving continence without ‘fixing’ the bladder neck.

Emerging drug therapies for benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the nonmalignant enlargement of the prostate gland caused by increases in number of both epithelial and stromal cells. Clinically, BPH leads to voiding dysfunction, which is most often referred to as lower urinary tract symptoms (LUTS). Historically, the only treatments for LUTS due to BPH were watchful waiting or surgery (transurethral or open prostatectomy). However, over the last 20 years medical therapy has taken a prominent role in the management of BPH. Current medical treatments for BPH include α-adrenergic receptor antagonists, inhibitors of the 5-α reductase enzyme and various phytotherapies. These agents are generally effective and safe; however, many patients are unable to tolerate the side effects or are refractory to medical management and require surgery. In light of this, many potential new therapies for the treatment of BPH are under development. Some represent a variation of current treatments, whereas others target novel molecular pathways within the prostate. The aim of this review is to examine current pharmacotherapies as well as to highlight emerging drugs that may improve our treatment of patients with LUTS secondary to BPH.

Urologist Practice Patterns in the Management of Peyronie's Disease: A Nationwide Survey

INTRODUCTION Peyronies disease (PD) is a poorly understood clinical entity. Aim. We endeavored to determine how contemporary urologists in the United States manage PD. METHODS A randomly generated mailing list of 996 practicing urologists was generated from the American Urologic Association member directory. A specifically designed survey was mailed with a cover letter and a postage-paid return envelope. MAIN OUTCOME MEASURE Our survey assessed several practice-related factors and asked questions of how the subject would manage various presentations of PD in their practice. Four cases were presented: case 1, a healthy 55-year-old man with painless 30 degrees dorsal curvature of 16 months duration; case 2, a 60-year-old man with 35 degrees dorsal curvature, 4/10 pain on visual analog scale, of 6 months duration; case 3, a 62-year-old man with painless 60 degrees dorsal curvature and erectile dysfunction responsive to alprostadil suppository of 2 years duration; and case 4, a 50-year-old man with mid-shaft waist deformity, foreshortening, no pain/curvature/erectile dysfunction. RESULTS Responses were received from 236 (24%) practicing urologists. Vitamin E was the preferred initial management for 70% of respondents, with observation, Potaba (Glenwood, Englewood, New Jersey, USA), colchicine, verapamil injections, and verapamil gel favored by 32, 20, 12, 7, and 10% of respondents, respectively. Fifty-seven percent of respondents performed surgery for PD, with penile prostheses, Nesbit procedure, grafting, and plication used by 76, 66, 55, and 51% of respondents, respectively. Medical therapy and/or observation was the preferred management for all of the cases except case 3, for which penile prosthesis placement and referral were the favored options by 39 and 30% of urologists, respectively. CONCLUSIONS Medical therapy is the initial treatment for PD among American urologists. Penile prosthesis is the treatment of choice in impotent patients. Most American urologists conform to recommended practice patterns in the management of PD.

Effect of Reclassification on the Incidence of Benign and Malignant Renal Tumors

PURPOSE The incidence of benign renal tumors has increased in recent years. This trend is commonly attributed to the increased use of cross-sectional imaging and minimally invasive surgical approaches. An alternative hypothesis is that recent changes in histological classification are responsible for the increasing incidence. To further investigate the impact of histological reclassification we reexamined all excised renal masses using the 2004 WHO criteria and compared this histological classification to the prior criteria. MATERIALS AND METHODS We identified 1,101 consecutive partial and radical nephrectomy cases managed at our institution from 1989 to 2003. All histopathological sections were rereviewed by a single pathologist and reclassified according to 2004 WHO criteria. The percentages of benign lesions per year according to the prior histological and current WHO 2004 histological criteria were compared. RESULTS Of the 1,101 renal masses 132 (12.0%) and 165 (15.0%) were classified as benign using prior and current WHO criteria, respectively. On average the WHO criteria diagnosed more benign tumors per year than the prior criteria (p = 0.004). Linear regression demonstrated a similar, persistent increase in benign diagnoses per year of 0.69% (WHO) and 1.22% (prior) during the 14-year period (p = 0.33). All masses reclassified as benign were oncocytoma (33). CONCLUSIONS Implementation of the 2004 WHO criteria is contributing to the increase in diagnosis of benign renal lesions, specifically oncocytoma. Changes in histological classification do not account for the entire increase. Other factors, which remain to be delineated, are also contributing to the increase in the diagnosis of benign renal lesions.

1344: Transobturator Sling with Intraoperative Cough Test is Effective for Patients with Low Valsalva Leak Point Pressure

OBJECTIVE The transobturator sling (TOS) is safe and effective for the treatment of female stress urinary incontinence (SUI). Controversy exists regarding its efficacy in patients with low valsalva leak point pressure (VLPP), a marker of intrinsic sphincter deficiency (ISD). We review our experience of TOS in the treatment of women with SUI and low VLPP. METHODS Patients diagnosed with stress or mixed incontinence treated with TOS were identified by retrospective review. All procedures were performed with local anesthesia and intravenous sedation. Stress incontinence and VLPP were determined preoperatively with urodynamic testing. Chart review identified demographics, perioperative variables, complications, and subjective cure. Low VLPP was defined as VLPP less than 60 cm H2O. RESULTS From November 2003 to February 2006, 151 consecutive women underwent TOS. Twenty-seven patients were excluded who exhibited incontinence with cough but not valsalva on preoperative urodynamic testing. Of the remaining 124 patients, 29% had low VLPP and 71% had higher VLPP. There was no difference in subjective cure between patients with low (94%) and higher VLPP (84%) overall (p = 0.12) or in patients with 12 months or more of follow-up (93% versus 79%, p = 0.40). Patients with low VLPP were more likely to be older (p = 0.036), and have pure SUI (p = 0.019). CONCLUSIONS TOS is effective for patients with low VLPP. Women with SUI and ISD without a fixed urethra should be considered candidates for TOS. The use of intravenous sedation during sling placement allows the surgeon to perform an intraoperative cough test, permitting tensioning of the TOS in relation to the patients ISD.

De novo Overactive Bladder Symptoms After a Sling

A 45-yr-old woman with pure stress urinary incontinence (SUI) undergoes a sling procedure. Preoperatively, she had no irritative voiding symptoms and no voiding complaints. After the sling is done, she notes some mild increase in her urinary frequency. At her 6-wk follow-up visit, she complains of onset of urge incontinence requiring two pads per day. She has no SUI. She notes her stream has slowed a bit since the surgery.

Long-term outcomes of the distal urethral polypropylene sling procedure for stress urinary incontinence

Long-term outcomes of the distal urethral polypropylene sling procedure for stress urinary incontinence