Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique

PurposeBladder neck contracture (BNC) is a well-recognized complication following robot-assisted radical prostatectomy (RARP) for treatment of localized prostate cancer with a reported incidence of up to 1.4%. In this series, we report our institutional experience and management results.MethodsA prospectively collected database of patients who underwent RARP by a single surgeon from 2006 to 2012 was reviewed. Watertight bladder neck to urethral anastomosis was performed over 18-French foley catheter. BNC was diagnosed by flexible cystoscopy in patients who developed symptoms of bladder outlet obstruction. Subsequently, these patients underwent cold knife bladder neck incisions. Patients then followed a strict self regimen of clean intermittent catheterization (CIC). We identify the patient demographics, incidence of BNC, associated risk factors and success of subsequent management.ResultsTotal of 930 patients who underwent RARP for localized prostate cancer was identified. BNC was identified in 15 patients, 1.6% incidence. Mean patient age and preoperative prostate-specific antigen was 58.8 years old and 7.83 ng/mL (range, 2.5-14.55 ng/mL) respectively. Mean estimated blood loss was 361±193 mL (range, 50-650 mL). Follow-up was mean of 23.4 months. Average time to BNC diagnosis was 5.5 months. In three patients, a foreign body was identified at bladder neck. On multivariate analysis, estimated blood loss was significantly associated with development of BNC. All patients underwent cystoscopy and bladder neck incision with a 3-month CIC regimen. Out of 15 index patients, none had a BNC recurrence over the follow-up period.ConclusionsBNC was identified in 1.6% of patients in our series following RARP. Intraoperative blood loss was a significant risk factor for BNC. In 20% of BNC patients a migrated foreign body was noted at vesicourethral anastomosis. Primary management of patients with BNC following RARP should be bladder neck incision and self CIC regimen

Challenging non-traumatic posterior urethral strictures treated with urethroplasty : a preliminary report

Introduction: Posterior urethral strictures after prostatic radiotherapy or surgery for benign prostatic hyperplasia (BPH) refractory to minimal invasive procedures (dilation and/or endoscopic urethrotomy) are challenging to treat. Published reports of alternative curative management are extremely rare. This is a preliminary report on the treatment of these difficult strictures by urethroplasty. Materials and Methods: Seven cases were treated: 4 cases occurred after open prostatectomy or transurethral resection of the prostate for BPH, one case after external beam irradiation and 2 after brachytherapy. The 4 cases after BPH-related surgery were in fact complete obstructions at the bladder neck and the membranous urethra with the prostatic urethra still partially patent. Anastomotic repair by perineal route was done in all cases with bladder neck incision in the BPH-cases and prostatic apex resection in the radiotherapy cases. Results: Mean follow-up was 31 months (range: 12-72 months). The operation was successful, with preserved continence, in 3 of the 4 BPH-cases and in 2 of the 3 radiotherapy cases. An endoscopic incision was able to treat a short re-stricture in the BPH-patient and a longer stricture at the bulbar urethra could be managed with a perineostomy in the radiotherapy-patient. Conclusion: Posterior non-traumatic strictures refractory to minimal invasive procedures (dilation/endoscopic urethrotomy) can be treated by urethroplasty using an anastomotic repair with a bladder neck incision if necessary

The clinical effectiveness of transurethral incision of the prostate : a systematic review of randomised controlled trials

The original publication is available at www.springerlink.com.Peer reviewedPostprin

Holmium Laser Enucleation of the Prostate

Introduction: Holmium laser enucleation of the prostate (HoLEP) offers superior voiding outcomes to traditional transurethral resection and less morbidity than open simple prostatectomy. Likewise, HoLEP has been determined to result in excellent outcomes regardless of gland size. We present a step-by-step surgical approach to HoLEP describing both the traditional enucleation technique and a modified “top-down” surgical technique. Materials and Methods: In this video, two techniques are presented that were performed by two (A.E.K., J.E.L.) surgeons at our institution. Results: In the examples of the two enucleation techniques mentioned, outcomes are similar with regard to surgical and functional outcomes. Conclusions: HoLEP as a treatment for BPH with associated lower urinary tract symptoms (LUTS) results in excellent patient outcomes and can be offered to patients regardless of prostate volume

Impacts of chronic stress on urinary bladder function & recovery through modification of PACAP signaling

Stress can cause or contribute to bladder dysfunction though specific effects remain unclear. Individuals with interstitial cystitis (IC)/bladder pain syndrome (BPS) experience increased symptom severity with stress, including pain and increased urgency and frequency of voiding. Further research can identify stress-related changes to urinary mechanisms, such as changes in sensory neurotransmitters and subsequent receptor expression. These factors could then become targets for future therapies providing bladder dysfunction relief. Alterations in PACAP and TRPV channel expression have been shown in sensory pathways in response to disease. My research studied the effects of chronic stress on bladder function and the potential for PACAP(6-38), a PACAP antagonist, to recover normal function. Mice went through a repeated variate stress regime followed by bladder tube implant and cystometrogram recording. Bladder, dorsal root ganglia (DRG), and spinal cord tissues were collected and immunostained for the presence of TRPV1, TRPV4, and PACAP expression. Chronic stress decreased inter-contraction interval (ICI) and bladder capacity while increasing bladder pressures. Both control and stressed male and female mice showed improvement following a 30-minute intravesical infusion of PACAP(6-38), with ICI and bladder capacity measures having the most consistent improvement across groups. PACAP and TRPV1 expression was upregulated in the bladder afferent pathway. These findings suggest that chronic stress can contribute to bladder dysfunction, and it seems to be mediated in part by upregulation of PACAP and TRPV channel activity. With further research, these factors may be valid molecular targets for therapy. As chronic stress may present alone or in combination with other conditions (IC/BPS, injury, etc.), it is critical to understand stress-related changes in order to reduce or eliminate their impact

Transurethral Incision of the Bladder Neck in a Woman with Primary Bladder Neck Obstruction after Kidney Transplantation

Voiding dysfunction is frequently seen in the early posttransplant period. Among other causes, this condition can arise due to bladder outlet obstruction. Primary bladder neck obstruction (PBNO) is a possible but very rare cause of bladder outlet obstruction. We present the case of a 52-year-old woman who, after kidney transplantation, presented with PBNO. The diagnosis was established based on symptoms, uroflowmetry, and multichannel urodynamics with electromyography. The transurethral incision of the bladder neck was made at the 5- and 7-o’clock position. After the operation, the maximal flow rate was significantly increased, and postvoid residual urine was decreased compared to the preoperative findings. The patient was followed for 5 years, and her voiding improvement is persistent. This is the first reported case of PBNO treated with a transurethral incision of the bladder neck in a posttransplantation female patient

KOREKCIJA CISTOKELE SINTETSKOM MREŽICOM TRANSOBTURATORNIM PRISTUPOM (PERIGEE SISTEM)

Objectives. Our first short-term results of transobturator mesh interposition (Perigee System) for the correction of cystoceles are presented. Methods. This is our initial study on 22 women with cystocele > Grade 2 who underwent the Perigee procedure in our Center between January 2006 and March 2007. In 15 cases lateral cystocele defect was ¬diagnosed, whereas other 7 patients had central anterior vaginal wall defect. All patients were assessed by POP-Q staging. Results. The anatomical and functional reconstruction of anterior vaginal wall was achieved in all patients. Preoperatively, mean POP-Q Aa value was +1.1 (± 0.3) and Ba value was + 1.9 (± 1.3) . No major intraoperative or immediate postoperative complications were observed. One and three months postoperatively, mean POP-Q Aa value was – 2.9 (± 0.21) and – 2.82 (± 0.1) respectively and Ba was –2.85 (± 0.4) and – 2.8 (± 0.23) respectively. Patients’ satisfaction and the imposing short-time surgical outcome were achieved in all cases after three months follow-up. Conclusion. We consider Perigee procedure to be highly efficacious, minimally invasive and easy technique for correction of anterior vaginal wall defects.Cilj rada. Prikazati preliminarne rezultate transobturatornog pristupa korekcije cistocela metodom Perigee. Metode. 22 bolesnice s cistocelom drugog stupnja podvrgnute su u našoj ustanovi metodi Perigee u vremenskom razdoblju između sječnja 2006. i ožujka 2007. godine. U 15 bolesnica dijagnosticirano je lateralno paravaginalno oštećenje, dok je u 7 bolesnica verificirano centralno oštećenje prednje vaginale stijenke. Rezultati. Anatomska i funkcionalna korekcija prednje vaginalne stijenke ovom metodom postignuta je kod svih bolesnica. Preoperativno, srednja vrijednost POP-Q Aa točke bila je +1.1 (± 0.3) a Ba točle + 1.9 (± 1.3). Nije bilo intraoperativnih ni perioperativnih komplikacija zahvata. Jedan i tri mjeseca nakon zahvata, srednja vrijednost točke POP-Q Aa bila je – 2.9 (± 0.21) i – 2.82 (± 0.1) dok je srednja vrijednost točke Ba bila –2.85 (± 0.4) i – 2.8 (± 0.23). Zaključak. Smatramo da je Perigee metoda jednostavna, ¬neinvazivna i učinkovita metoda korekcije defekata svih tipova cistokela

Interstitial laser therapy of benign prostatic hyperplasia

The objective of interstitial laser coagulation (ILC) of benign prostatic enlargement is to achieve a marked volume reduction and to decrease bladder outlet obstruction and lower urinary tract symptoms with minimal morbidity. Coagulation necrosis is generated well inside the adenoma by means of specifically designed laser applicators combined with either a Nd:YAG laser or a diode laser. Because the laser applicators can be inserted as deeply and as often as necessary, it is possible to coagulate any amount of tissue at any desired location while preserving adjacent structures such as the urethra. Postprocedural, the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes, rather than sloughing of necrotic tissue. Several single-armed and randomized studies indicated the effectiveness of interstitial laser coagulation of BPH-syndrome. Marked improvements in AUA score, peak flow rate, residual urine volume and prostate volume were reported. Pressure-flow studies demonstrated a sufficient decrease of the intravesical/detrusor pressure, urethral opening pressure and urethral resistance. Long-term results demonstrating sustained success for up to 3 years were reported on a series of 394 patients. ILC is suitable to debulk even large prostates and to treat highly obstructive patients. Therefore, ILC can be seen as a true alternative to TURF with certain advantages, such as almost no serious morbidity and with certain disadvantages, such as the need for postoperative catheterization. However, ILC can be done under local anesthesia and does not require hospitalization

A casemix analysis of hospital admissions in six specialties for Barking & Havering Health Authority.

To examine admission rates for Barking & Havering residents to six surgical specialties by first looking at elective, emergency and total workloads, then at the casemix of elective work using Healthcare Resource Groups. To compare findings to other London areas

Long-term complications of continent catheterizable channels: a problem for transitional urologists.

A majority of the transitional urology patient population have neurogenic bladder and many of these patients have undergone creation of continent catheterizable channels (CCCs) to facilitate bladder emptying. Transitional urologists will be faced with revision of these channels due to a variety of possible complications. We performed a comprehensive literature review to the data regarding the incidence, timing, and predisposing factors that lead to complications of CCCs as well as surgical revision techniques and their outcomes. Long-term channel complications and related revisions are common (25-30%) and likely underestimated. While many predictors for revision have been posited, the only predictor that has been significant in robust multivariable analysis is channel type, with appendicovesicostomies having a lower chance of requiring revision compared to Monti channels. Channels created in adults have high likelihood of requiring revision, even within a relatively short follow-up period. We review techniques for management of channel complications and their outcomes. As patients with congenital urologic conditions requiring CCCs are gaining longer lifespans, transitional urologists will be faced with revision and/or replacement of these channels. While some of these patients may require supravesical diversion in the future, data show that revision is feasible with good outcomes. Longer-term follow-up data is needed to understand the life-span and best practices of new CCCs created among the transitional population