Congenital lower urinary tract obstruction and enuresis in children

We reviewed enuretic children among patients with congenital lower urinary tract obstructions experienced in the Department of Urology, Hyogo College of Medicine during 16 years from 1974 to 1989. Among 612 patients with congenital lower urinary tract obstructions, 139 (22.7%) had enuresis nocturna and/or diurna. The incidence of enuresis was 24.7% with posterior urethral valve (77 cases), 50.0% with anterior urethral valve (6 cases), 23.8% with congenital bulbar urethral stenosis in boys (303 cases) and 19.9% with congenital distal urethral stenosis in girls (226 cases). Diurnal enuresis was more common in enuresis associated with congenital lower urinary tract obstructions than in usual enuresis. In urodynamic examinations, more than half of enuretic children with congenital lower urinary obstructions showed hyperactive detrusor activity. Treatment of congenital lower urinary tract obstructions through operation resulted in cure or amelioration of enuresis in about 80% of the patients. Enuresis associated with lower urinary tract obstruction or neurogenic bladder is sometimes called complicated enuresis and it is an important role of a urologist to differentiate complicated enuresis from simple enuresis.     

Bilateral endometriosis of the ureter

A case of bilateral endometriosis of the ureter with bilateral ureteral obstruction is reported. Ureteroscopy failed to detect endometriosis, and only bilateral partial ureterecomy with end-to-end anastomosis revealed the diagnosis. Bilateral endometriosis is very rare. Either extrincic periureteral compression or intrinsic involvement of the ureteral wall causes ureteral obstruction, and may destroy the kidneys with few or no gynecological or urological symptoms. To facilitate early diagnosis and the initiation of appropriate therapy, the gynecologist should regularly search for clinical signs and symptoms of upper urinary tract obstruction in all women with genital endometriosis or a history of previous surgery for genital endometriosis. When renal ultrasound shows upper urinary tract dilatation, ureteral endometriosis should be suspected. The urologist should think of ureteral endometriosis in a premenopausal woman with unilateral or bilateral distal ureteral obstruction of unknown cause, especially when she suffers from genital endometriosis or has a history of this disease.     

First-line treatment for symptomatic benign prostatic hyperplasia: is there a particular patient profile for a particular treatment?

When the range of treatment options for benign prostatic hyperplasia (BPH) is as broad as the BPH spectrum of symptoms, how should urologists and their patients choose the best initial treatment? Treatment goals should include reducing both lower urinary tract symptoms and relieving associated morbidities, such as urinary retention, persistent gross hematuria, recurrent infections, bladder stones, or renal insufficiency—which are all indications for surgery. However, if one views BPH as a chronic and progressive disease, should a primary goal of BPH management be the prevention of the BPH-associated morbidities? The goal of this paper is to provide a literature update regarding various treatment options in the setting of initial treatment for symptomatic BPH. Novel approaches to BPH management are discussed. In all cases, the risks and benefits of each treatment need to be considered and discussed with the patient; the decision is ultimately up to the patient and his urologist.     

Urodynamic procedures: Recommendations of the Urodynamic Society. I. Procedures that should be available for routine urologic practice

This report details the recommendations of the Urodynamic Society on urodynamic procedures. It was the unanimous opinion of the members of the task force that the practicing urologist should have access to cystometry, voiding cystourethrography, and estimation of urinary flow rate and postvoid residual urine volume. Knowledge of these parameters coupled with history, physical examination, and appropriate laboratory data permits effective treatment of the vast majority of patients with lower urinary tract disorders. Urethral pressure profilmetry, sphincter electromyography, and combined multichannel urodynamic procedures are not necessary for the routine practice of urology.     

Inguinal hernia containing urinary bladder—A case report

IntroductionInguinal bladder hernia is rare condition found in about 1–5% of inguinal hernias. The condition is usually diagnosed intraoperatively. Patients rarely have symptoms regarding urinary tract. The best management is surgical, open surgical technique is preferred over laparoscopic. Possible urinary tract damage during surgery should be recognized and resolved.Case presentationThe following paper presents case of inguinal bladder hernia in 82-year old Caucasian male. Patient presented at our emergency department with incarcerated left inguinal hernia. Preoperative ultrasound has shown small bowel loop inside hernia sac. The condition was diagnosed intraoperatively – the whole bladder was found inside hernia sac. During surgery minor damage of the bladder was caused and repaired. Hernia defect was repaired using Bassini hernioplasty.DiscussionElderly male more often present with inguinal bladder hernia. Sometimes urinary malignancy may be cause for inguinal bladder hernia. In cases where inguinal bladder is found inside hernia sac, urologist should be consulted to exclude urological pathology. Surgical treatment is indicated in all symptomatic patients. Patients with small, asymptomatic inguinal bladder hernias could be treated conservatively.ConclusionPhysicians seeing patients with inguinal hernia should be aware that patient may have inguinal bladder hernia, especially in patients presenting with newly developed symptoms of lower urinary tract.     

Urologic implications of anorectal malformations

The urologist has assumed a major role in the management of the child with imperforate anus. Fistulas from the rectum to the urinary tract, as well as associated genitourinary anomalies such as vesicoureteral reflux, make the urologist an important member of the team managing imperforate anus. Special spheres of urologic interest occur immediately (when accurate imaging is important), during the first year (when urinary tract infections and acidosis may occur), and in later childhood and adolescence (when the management of neurogenic bladder or complications of previous repairs of the anorectal anomaly are important).     

Transitional-cell carcinoma of the renal pelvis: ureteroscopic and percutaneous approach

There are a variety of publications advocating the ureteroscopic or the percutaneous approach for the treatment of transitional cell carcinoma of the renal pelvis. The diagnostic tool of choice for the upper urinary tract and collecting system is the flexible ureteroscope. One of the major concerns about ureteroscopic management of renal disease initially was the lack of flexibility of the instruments and therefore the inability to deal with demanding sites. The advent of new ureteroscopic techniques, as well as the continuous evolution of the technology, have paved the way for safe and effective access to the upper urinary tract. In the hands of an experienced urologist, such procedures can provide reliable treatment options for small upper urinary tract lesions. Coupling minimal morbidity with ever-improving optics and flexibility, the ureteroscope of today leaves no area of the urinary tract unseen. In patients with bulky tumors or in whom easy access and resection is not possible ureteroscopically, the percutaneous approach to the renal pelvis, although more invasive, provides a better working environment. Clearly, the most difficult aspect of ureteroscopic access to the lower pole is not just visibility but the loss of deflection caused by passage of various instruments through the working channel. Direct access via percutaneous approach with a large resectoscope avoids these problems.     

Urologische Betreuung von Patienten vor und nach Nierentransplantation

Patients with end-stage renal disease awaiting kidney transplantation require regular urological evaluation. The urologist's main task is early diagnosis and treatment of genitourinary malignancies and evaluation of the lower urinary tract. Furthermore, urologists are often confronted with the question of whether or not to perform pretransplant urological surgery, i.e., native nephrectomy for polycystic kidney disease. Urological care after kidney transplantation involves diagnosis and treatment of ureteral complications, malignancies, lower urinary tract symptoms, and last but not least erectile dysfunction, which has a prevalence of 20-50% among kidney transplant recipients.For the evaluation and follow-up of the living kidney donor, international guidelines have been developed in recent years to also help the urologist to perform a correct evaluation and follow-up of the kidney donor.     

Protection of a body cast in an infant

A technique for obtaining multiple urograms is presented which can be used in the average clinic or hospital, requiring no special and expensive apparatus.Complete cooperation between the urologist and the roentgenologist is essential.Fluoroscopy is an important part of the technique.Pressure, other than gravity, should not be used in the filling process.The advantages of the technique given are considered.The entire urinary tract, as well as extra-urinary structures, is included in the field of study.     

The introduction of an urodynamic technic synchronized with videocystourethrograms and its data management

The video urodynamics that simultaneously display urodynamic data with radiographic visualization of the lower urinary tract on television monitors was first described by Miller in 1967. This technique has been developed in a growing number of urodynamic laboratories in North American and European countries. The 2100 uro color video system manufactured by DISA elektronik A/S was introduced into our clinic in September in 1984. We have been aware of the lack of a satisfactory way of measuring the function of the bladder neck and posterior urethra during micturiton. But now, from our experience using this system, we conclude that video urodynamics is a comprehensive means of assessing, lower urinary tract disorders.     

The value of ultrasound scanning of the upper urinary tract in patients with bladder outlet obstruction

Ultrasound scanning of the upper urinary tract enables a urologist to allocate a degree of urgency for surgery when upper tract dilatation is present. We have studied whether other assessments of bladder outlet obstruction could eliminate this investigation. The study group comprised 223 consecutive patients who had ultrasound scans for bladder outlet obstruction. Estimation of urea, creatinine, residual urine and flow rate could not predict the presence of upper tract dilatation and it was concluded that ultrasound scanning of the upper tracts should continue to be used as a means of deciding how urgently a patient requires prostatic surgery.     

Voiding dysfunction in children

The practicing urologist commonly sees children with lower-urinary tract dysfunction who wet or have recurrent urinary tract infections. This article identifies the proposed etiologies of such behavior in children in whom there are no anatomic or neuropathic causes, outlines the approach to evaluating affected children, and describes a stepwise,interdisciplinary approach to treatment.     

Secondary and miscellaneous urolithiasis. Medications, urinary diversions, and foreign bodies

Secondary stones, those with no "classic" cause, provide unusual diagnostic and treatment challenges to the urologist. Stones related to medications, to urinary diversions or augmentation, or to presence of foreign bodies within the urinary tract occur rarely. Nevertheless, they represent situations that may be corrected fully by appropriate conservative or procedural therapy, and therefore they must be included in the differential diagnosis of many patients who present with symptoms of urolithiasis.     

Ultrasonography of the kidney

Summary Office-based renal sonography provides the urologist with cost-effective and noninvasive means of imaging the upper urinary tract. A majority of transrectal sonography units currently on the market can be easily adapted to transabdominal use by the purchase of one additional transducer. This enables the urologist to rule out hydronephrosis sonographically and to follow patients with known upper-tract disease who have previously undergone radiographic studies. In contrast, the differential diagnosis of upper-tract mass lesions requires a much more advanced level of training and experience. For patients at low risk of developing renal tumor, e.g., patients with BPH, renal ultrasound should replace contrast-enhanced imaging studies.     

Sexual dysfunction in the patient with prostatitis

Prostatitis (chronic prostatitis/chronic pelvic pain syndrome [CP/CPPS]) is a common condition in men that accounts for a significant number of visits to a medical doctor or urologist. It is one of the most widely diagnosed conditions in men who attend urologic clinics. Erectile dysfunction, defined as the consistent inability to obtain and/or maintain a penile erection sufficient for adequate sexual relations, also is a common problem. This review explores the links between sexual dysfunction and prostatitis. Most of the data linking lower urinary tract symptoms and erectile dysfunction suggest that lower urinary tract symptoms impair the overall quality of life and that a low quality of life contributes to or causes erectile dysfunction. Prostatitis-like symptoms such as perineal, penile, and suprapubic discomfort or pain during or after ejaculation and voiding complaints such as irritative and obstructive voiding symptoms (urinary frequency, urgency, and dysuria) may affect the global emotional well-being of a man. Erectile dysfunction also is strongly associated with a negative impact on the quality of life. The available literature demonstrating the influence of CP/CPPS on the incidence of erectile dysfunction is scant. From the literature, it is known that lower urinary tract symptoms and benign prostatic hyperplasia are definitely related to erectile dysfunction. Any kind of pain is likely to be the most significant symptom in men with CP/CPPS as it relates to sexual dysfunction. Sexual dysfunction such as ejaculation discomfort is described as a symptom of CP/CPPS. Most of the data linking the two suggest that CP/CPPS impairs the overall quality of life and it is this that contributes to or causes erectile dysfunction.     

Sakrale Neuromodulation in der Behandlung von Funktionsstörungen des unteren Harntrakts

Over the last few years, sacral neuromodulation has become an established treatment option for dysfunctions of the lower urinary tract. It fills the gap that used to exist between conservative therapy and costly invasive methods such as urinary drainage via a deactivated bowel segment. Initially, the clinical value of sacral neuromodulation was controversial even among neurourologists. This was mainly due to a lack of understanding of the physiological processes, uncertain diagnostics, the design of the hardware, and a surgical topography relatively unknown to the urologist. In the meantime, however, sacral neuromodulation has become a standard part of clinical routine with respect to the treatment of dysfunctions of the lower urinary tract, and it is regularly employed in various urological institutions across Europe and the USA. This form of treatment, which is the final straw for patients who believed themselves-after many frustrated therapy attempts-to be "hopeless cases," can now also successfully be employed as an ambulatory measure. The latest data from our hospital, as well as contributions presented at the last DGU Congress in Wiesbaden, indicate that patients with neurogenic urinary retention are the most likely to profit from this treatment option.     

Percutaneous nephrolithotomy. Experience with renal and proximal ureteral calculi at Tygerberg Hospital

Percutaneous nephrolithotomy (PCN) enables the urologist to remove upper urinary tract stones through a percutaneous nephrostomy tract. The principal advantages of PCN are the low morbidity, shortened hospital stay and rapid recovery. Percutaneous puncture failed in 5 (11%) of the first 44 patients with upper tract urolithiasis treated by PCN at Tygerberg Hospital. In 35 patients (80%) PCN cleared the kidney of stones but in 4 patients (9%) all stone fragments were not removed during the procedure. If the puncture and dilatation was successful, then 90% of patients were stone-free after PCN. Complications were minimal except for a diabetic who died of septicaemia. PCN is an alternative to open renal surgery in the management of most upper urinary tract stones. The technique is readily mastered by any urologist experienced in endoscopic surgery.     

Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women

The problem with recurrent urinary tract infections in women is enormous and contributes significantly to national health care costs. As the role of office urology and the external "cost-effective" pressures placed on the practicing urologist have heightened, a consistent, logical approach towards diagnosis and management of urinary tract infection becomes essential. This article briefly discusses the cause and pathophysiology behind recurrent urinary tract infections in women. A practical discussion of proper evaluation and treatment options will also be provided in hopes of offering the clinician a simple, stepwise approach to this sometimes difficult condition.     

Reconstructive surgery for urinary incontinence

The clinical urologist often is faced with the referral of a patient with urinary incontinence refractory to conservative measures. Given the broad spectrum of causes of urinary incontinence, the clinician must base evaluation and therapeutic management on current principles of urinary tract pathophysiology. This article organizes the pertinent diagnostic considerations that must be addressed in guiding the clinician to the appropriate surgical treatment option.