Victor A. Politano

Periurethral Polytetrafluoroethylene Injection for Urinary Incontinence

AbstractWe have treated 165 patients with urinary incontinence from a wide variety of causes with periurethral polytetrafluoroethylene injections. Results have been good to excellent in approximately 75 per cent of the cases. Injections have averaged less than 2 per person. Complications have been minimal and the procedure is well tolerated. Polytetrafluoroethylene injections do not contradict subsequent surgery should it become necessary.

Polytetrafluoroethylene Injection for Urinary Incontinence in Children

We have treated 11 children for urinary incontinence with one or more endoscopic injections of polytetrafluoroethylene (Teflon) into the external urethral sphincter region. The procedure is simple to perform and without significant complications. Long-term results have been gratifying, with cure or improvement in 8 of the 11 patients.

Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir

A continent colonic urinary reservoir was created in 10 patients who had undergone anterior exenteration for invasive bladder carcinoma. A tapered distal ileal segment with a catheterizable abdominal stoma provided full continence in all 10 patients. Tapering of the terminal ileum was achieved with a gastrointestinal anastomosis stapler in 5 patients or with a bowel clamp in 5 others. Three purse-string sutures of 2-zero silk were placed on the tapered ileal segment to increase the intraluminal pressure. A nontunneled ureterocolonic anastomosis was performed in all 20 ureters. No obstruction or reflux was noted in 19 ureters (95 per cent). Hydronephrosis at the anastomotic site was noted in 1 ureter and was successfully dilated percutaneously.

Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary?

Objectives. To evaluate the use of interposition flaps in repairing vesicovaginal fistulas (VVFs) of benign and malignant etiologies. Interposition flaps are not routinely used in the repair of VVFs when the surrounding tissues appear healthy and well-vascularized, such as in a benign etiology.Methods. We retrospectively reviewed the charts of 37 women (mean age 49.1 years) at our institution who underwent transabdominal repair of their VVF by urologic surgeons between August 1978 and June 1999. The preoperative and postoperative medical records were reviewed.Results. Of the 37 VVFs repaired transabdominally, 29 had a benign etiology (25 related to gynecologic procedures) and 8 a malignant etiology (all related to gynecologic neoplasia). Of the 29 benign VVFs, an interposition flap was used in 10 repairs with all 10 successful (100%). The remaining 19 benign VVF repairs were performed without using a flap, with 12 successful (63%). Of the 8 malignant fistulas, an interposition flap was used in 2 repairs with both successful (100%). The remaining 6 malignant VVF repairs were performed without a flap, with 4 successful (67%).Conclusions. The results of our study indicate a higher success rate for transabdominal VVF repairs performed with an interposition flap (100% success rate at our institution). This observation holds true regardless of the appearance of healthy surrounding tissue or, more importantly, a benign or malignant etiology. We recommend interposition flaps in transabdominal repairs of VVFs, even in the cases of benign fistulas with well-preserved surrounding tissue.

Female Urinary Incontinence: Preoperatiye Selection, Surgical Complications and Results

A total of 98 women with stress urinary incontinence underwent surgical repair via 3 different techniques: 38 patients underwent a Burch colposuspension (group 1), 25 underwent a Stamey procedure (group 2) and 35 had a modified Pereyra operation (group 3). The main indication for an operation was clinically unacceptable incontinence, and urodynamic studies were done on all patients with associated stress and urge incontinence or who underwent reoperation. Subtracted bladder pressure recording was an important preoperative screening tool, since patients with high pressure instability did worse surgically than those with a stable bladder or low pressure instability. In patients with detrusor stability similar results were achieved for initial surgery and reoperations. Among the patients with a stable bladder with and without a previous anti-incontinence operation the over-all results were better in groups 1 and 3 than in group 2. Complications were of lesser magnitude in groups 2 and 3 than in group 1.

Transurethral Polytetrafluoroethylene Injection in Female Patients With Urinary Continence

We present our results with the use of transurethral injection of polytetrafluoroethylene (Teflon) in 128 female patients with moderate to severe urinary incontinence from 1964 to 1991. Of the patients 60% had undergone previous surgical treatment for the incontinence. The etiologies included stress incontinence, neurogenic bladder, congenital anomalies, trauma and others. More than 73% of the patients improved (54.3% were totally dry). The failure rate was 27%. Complications were minimal. Urinary tract infection and temporary urinary retention occurred in 7 and 6 patients, respectively. Mean followup was 31 months. This study demonstrates that transurethral polytetrafluoroethylene injection is a useful treatment of moderate to severe urinary incontinence in female patients. Polytetrafluoroethylene is particularly useful for patients with failed previous incontinence procedures and poor surgical candidates. Failures are more likely in patients with periurethral fibrosis secondary to a previous urethral operation.

Ureteropelvic Junction Obstruction Resulting from Percutaneous Cyst Puncture and Intracystic Isophendylate Injection: An Unusual Complication

AbstractA case is reported of an iatrogenic ureteropelvic junction obstruction caused by percutaneous renal cyst decompression and an attempt at sclerosis with the intracystic sclerosing agent isophendylate.

Sphincterotomy Failure in Neurogenic Bladder Disease

Among 60 spinal cord injury patients who underwent external urethral sphincterotomy 45 experienced success and 15 failed. Failure was established when symptomatic urinary tract infections and high vesical residuals persisted. Urodynamic findings demonstrated detrusor areflexia in 10 patients (66 per cent), detrusor-sphincter dyssynergia in 2 (13.2 per cent), detrusor hyperreflexia with unsustained bladder contractions in 1 (6.6 per cent), and detrusor hyperreflexia and bladder neck obstruction in 2 (13.2 per cent). Among these failures poor detrusor contractility predominated. Detrusor-sphincter dyssynergia may indicate an inadequate surgical relief of obstruction. Bladder neck obstruction may indicate that a bladder neck incision should be considered when an external sphincterotomy is performed.

THE ASSOCIATION OF ELEVATED URINARY TOTAL TO SULFATED GLYCOSAMINOGLYCAN RATIO AND HIGH MOLECULAR MASS HYALURONIC ACID WITH INTERSTITIAL CYSTITIS

PURPOSE A decrease in the glycosaminoglycan (GAG) layer on the urothelium is believed to be one of the possible causes of interstitial cystitis. Consequently, GAG-like substances and hyaluronic acid (HA) have been prescribed for treating this condition. To delineate the possible role of GAG and HA in the interstitial cystitis disease process, we compared the urinary levels of total GAGs (sulfated + non-sulfated), sulfated GAGs and HA in interstitial cystitis patients and normal controls. We also examined different HA species present in the urine of interstitial cystitis patients. MATERIALS AND METHODS The total GAG and sulfated GAG levels in urine specimens of normal individuals (n = 20) and interstitial cystitis patients (n = 25) were determined by utilizing the carbazole reaction assay and the Farndale method, respectively, and were expressed as microg./mg. creatinine. Urinary HA levels were measured by applying the HA test and were expressed as ng./mg. creatinine. Gel filtration column chromatography was used to examine the profile of urinary GAGs and HA species. RESULTS Total urinary GAGs were 2.5 to 4-fold elevated in interstitial cystitis patients with moderate to severe symptoms (Group 2; 76.2 +/- 24.8) when compared with those in normal individuals (19.9 +/- 2.5) and patients with mild symptoms (Group 1; 30.4 +/- 5.1) (p <0.001). Three urinary GAG peaks were detected in both normal and interstitial patients. However, each GAG peak from interstitial cystitis patient urine was 3 to 5-fold higher than that from normal patient urine. The sulfated GAG levels, however, remained unchanged among normal individuals (1.4 +/- 0.22), Group 1 (2.2 +/- 0.96) and Group 2 (1.6 +/- 0.38) patients (p >0.05). Consequently, the ratio of total GAGs to sulfated GAGs was elevated 3 to 3.5-fold in Group 2 patients (49.9 +/- 13.9) in comparison to that in normal individuals (16.7 +/- 2.5) and group 1 patients (14.4 +/- 4.6) (p <0.001). Urinary HA levels were marginally elevated in Group 2 patients (821. 4 +/- 247.9) when compared with those in the normal group (337.3 +/- 106.1) and Group 1 patients (540.9 +/- 166.5). In addition, a distinct high molecular mass HA species was present only in Group 2 patients. CONCLUSIONS The increased ratio of total GAGs to sulfated GAGs and marginally elevated HA levels in urine indicate that the GAG layer is altered in interstitial cystitis patients. However, these results are in contrast to the accepted concept that a reduction in urothelial GAGs causes interstitial cystitis. The high molecular mass HA species detected in patients with severe symptoms may play a role in the pathophysiology of this disease.

The Management of Spermatic Cord Liposarcomas

We review 3 cases of spermatic cord liposarcoma that have been followed for 12 months to 5 years after diagnosis. Inguinal orchiectomy rendered adequate treatment. Preoperative diagnosis of liposarcoma of the spermatic cord is unusual although gray scale sonography may be of some assistance. A review of the literature reveals that adjunctive medical or surgical treatment appears to be superfluous.