The management of post-prostatectomy vesical neck contracture.

Current evidence suggests that the small fibrous hyperplastic intraurethral prostate traumatized by wide extensive electroresection is the most important etiologic factor in post-prostatectomy vesical neck contracture. The preferred mode of management has not been well defined. Although transurethral resection is most often used recurrent contractures occur frequently. We report the complete objective and symptomatic relief of obstruction in 8 patients with post-prostatectomy bladder neck contracture treated with cold knife incision. This simple technique appears to obviate recurrent contracture and may well be the treatment of choice for this condition.     

Bladder neck resection and transurethral resection of the prostate: a randomized prospective trial

Transurethral resection of the prostate and bladder neck incision are accepted methods in the treatment of obstructive prostatic hyperplasia. Bladder neck incision is particularly useful in cases of small prostates. We have modified the method of bladder neck incision to bladder neck resection. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate (30 patients) and the new method of bladder neck resection. Bladder neck resection was comparable to transurethral resection of the prostate with respect to postoperative hospital stay, maximal flow rates and postoperative complications. Bladder neck resection was better than transurethral resection with respect to the operating time, transfusion requirement, volume of irrigation fluid and postoperative urinary infection. We conclude that bladder neck resection is the operation of choice in patients with a prostate of 30 gm. or less.     

Acute urinary retention associated with prostatic carcinoma

We describe the prospective evaluation of 90 patients seen at 2 medical centers who presented with acute urinary retention. All patients had a pre-retention history obtained, as well as careful prostate examination, perineal prostate biopsy and followup treatment or monitoring. Prostate cancer was found in 12 of the 90 patients (13.3 per cent), while 1 had metastatic leukemia to the prostate. Of the 90 patients 69 (76.7 per cent) had a palpably benign prostate and 2 malignancies (2.9 per cent) were diagnosed, while 11 malignancies occurred in 21 patients (52.4 per cent) with a suspicious examination. A total of 46 patients (51.1 per cent) underwent further prostate resection and no malignancy was found in any of these specimens: 43 underwent transurethral resection (24.9 gm. average), while 3 underwent open prostatectomy (97 gm. average). Other etiologies of acute retention included benign hyperplasia, other underlying illness, medical procedures, medications, prostatitis and prostatic infarction. Among the 44 patients who did not undergo prostatectomy 13 had treatment of the diagnosed cancer, 9 had resolution of retention and symptoms without intervention, 9 remained catheterized due to severe medical problems, 8 were treated for prostatitis, 2 had discontinuation of sympathomimetic drugs and 1 each underwent urethrotomy, bladder neck incision and resolution of prostatic infarction. In contrast to the older literature in which approximately 25 per cent of the patients presenting with acute urinary retention had prostate cancer, our data suggest a lower incidence. Prostatic biopsy for patients who present with acute urinary retention and a benign examination does not appear to be justified.     

Transurethral resection combined with steroid injection in treatment of recurrent vesical neck contractures.

Vesical neck contractures occur following 5 to 10 per cent of transurethral prostatectomies and an even smaller number of enucleative prostatectomies. Recurrences following both conservative and surgical treatment are common and present management problems to the urologist. Seven patients with recurrent vesical neck contractures were managed with reresection and steroid injection. One hundred per cent of patients responded to this although 1 patient required two procedures. The use of hydrocortisone sodium succinate (Solu-Cortef) versus triamcinolone acetonide (Kenalog) preparations are discussed.     

An objective comparison of transurethral resection and bladder neck incision in the treatment of prostatic hypertrophy

Transurethral resection has become the operation of choice in almost all cases of benign prostatic enlargement. However, when the gland does not exceed 30 gm. bladder neck incision is easier to perform, results in a lower morbidity, and is less likely to be followed by incontinence and retrograde ejaculation. We studied 2 groups of men with proved obstruction. Complete urodynamic investigation was done on 51 patients before and on 44 patients after the operation. We compared our subjective and objective findings in the 2 groups. The conclusion suggest that bladder neck incision is as effective as transurethral resection in relieving the obstruction of prostatic enlargement in the presence of a small gland.     

Coincident vesical transitional cell carcinoma and prostatic carcinoma. Clinical features and treatment

Twenty-two patients with vesical urothelial carcinoma associated with prostatic carcinoma were reviewed. They represented 1.5% of the bladder and prostatic tumours treated in our department within a 12-year period from 1968 to 1979. Their management included several treatment policies, based on the separate assessment of each tumour variant. For non-infiltrating bladder tumours, transurethral tumour resection was combined with hormonal treatment, external radiotherapy or resection of the prostate depending on the stage of the prostatic tumour. Radical cystoprostatectomy was performed for two cases of infiltrating bladder tumour with well localised prostatic tumours. A conservative primary approach seems justifiable in the management of double carcinoma of the bladder and prostate. The coincidence of bladder urothelial carcinoma and prostatic carcinoma per se is not an adverse prognostic factor; prognosis is more closely related to the pathological stage and grade of the bladder tumour. Cystoprostatectomy for patients with infiltrating bladder tumours could be curative, in selected cases, for the prostatic cancer as well.     

Transurethral incision of the bladder neck and prostate.

Between March 1983 and December 1988, 66 men 50 years old and older with symptomatic bladder outlet obstruction underwent transurethral incision of the bladder neck and prostate. Patients selected for incision had a small, clinically benign, prostate and peak urinary flow rate of less than 15 ml. per second. Preoperative and postoperative evaluation included symptom questionnaires and uroflowmetry. A single midline incision was made extending from the bladder neck to the verumontanum. Results were available in 64 of the 66 men who underwent the procedure with a mean followup of 2.24 years. Mean symptom scores decreased from 9.66 preoperatively to 4.59 postoperatively (p less than 0.001) and peak urinary flow rates increased from 7.4 to 14.7 ml. per second (p less than 0.0001). Antegrade ejaculation was preserved in 83.3% of the men who preoperatively had antegrade ejaculation. Subsequent transurethral resection of the prostate was required in 5 patients (7.6%). With a mean followup of greater than 2 years transurethral incision of the bladder neck and prostate was effective in treatment of bladder outlet obstruction caused by a small prostate while maintaining antegrade ejaculation in the majority of patients.     

Treatment of cervico-prostatic obstruction by endoscopic incision of the prostate. Apropos of 16 patients

Several teams over recent years have proposed deep transurethral incision of the prostate as treatment for obstructive symptoms secondary to primary bladder neck sclerosis or to a small prostatic adenoma. We have performed this technique in 16 patients over a period of 9 months: 9 cases of primary bladder neck sclerosis and 7 prostatic adenomas weighing less than 20 grams. There were no post-operative complications. This technique was definitely effective on the dysuria with 93% good results at 6 months. The preservation of post-operative anterograde ejaculation was less certain; 27% of our patients developed post-operative retrograde ejaculation. The indication for TUI amongst the other available surgical techniques depends on a rigorous pre-operative assessment evaluating the size and the nature of the obstruction. It is a remarkably simple technique which effectively cures the dysuria. It also markedly decreases the risk of retrograde ejaculation. As this complication is difficult to predict, the patients should be informed of the risks prior to the operation.     

Preoperative estimation of the size of prostatic adenomas

In a retrospective study the postoperative weight of one hundred prostatic adenomas was compared with the preoperative estimated size, based on rectal digital palpation. As a basis for the choice between transurethral and transvesical resection the adenomas were classified by digital palpation in three weight groups: less than 20 g, 20–40 g and more than 40 g. The objective was to avoid transvesical resection in small adenomas and transurethral resection in large ones, weighing more than 40 g. No adenomas weighing less than 20 g were removed transvesically. About one fourth of the adenomas removed transurethrally weighed more than 40 g. Forty-five per cent of the adenomas were placed erroneously into the 20 g group. Rectal digital palpation is a very unreliable method of assessing prostatic size, however, very small adenomas can be identified. Urethrocystoscopy can be of aid in identifying the very large ones.     

Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy

PURPOSE: Options for treatment of large (greater than 100 gm.) prostatic adenomas have until now been limited to open surgery or transurethral resection by skilled resectionists. Considerable blood loss, morbidity, extended hospital stay and prolonged recovery occur with open surgery for large prostatic adenomas. Endoscopic surgery for benign prostatic hyperplasia has evolved during the last decade to offer the patient and surgeon significant advantages of transurethral removal of prostatic adenomas. Holmium laser enucleation of the prostate with transurethral tissue morcellation provides significant reductions in morbidity, bleeding and hospital stay for patients with large prostate adenomas. MATERIALS AND METHODS: A retrospective review of data on 10 cases of holmium laser enucleation and 10 open prostatectomies for greater than 100 gm. prostatic adenomas was performed from 1998 to 1999 at our institution. Patient demographics, indication for surgery, preoperative and postoperative American Urological Association (AUA) symptom scores, operating time, serum hemoglobin, resected prostatic weight, pathological diagnosis, length of stay and complications were compared. RESULTS: Patient age, indications for surgery (retention, failed medical therapy, high post-void residual, bladder calculi, bladder diverticula and azotemia) and preoperative AUA symptom scores were similar in both groups. Postoperative AUA symptom scores were significantly decreased (p <0.004) in both groups. Operating times were not significantly different. Serum sodium was unchanged by holmium laser enucleation (not significant), and postoperative hemoglobin was not significantly reduced in the holmium laser enucleation group but decreased significantly in the open prostatectomy group (mean decrease 2.9 +/- 0.7 gm., p = 0.0003). Resected weight was greater in the holmium laser enucleation group (151 versus 106 gm., p = 0.07). Length of stay was significantly shorter in the holmium laser enucleation group (2.1 versus 6.1 days, p <0.001). Complications in the holmium laser enucleation group included stress urinary incontinence in 4 cases, prostatic perforation in 1 and urinary retention in 1. No patient treated with holmium laser enucleation was discharged home with an indwelling catheter. Complications in the open prostatectomy group included bladder neck contractures in 2 cases, stress incontinence in 1 and urge incontinence in 1. All patients treated with open prostatectomy were discharged home with an indwelling catheter. CONCLUSIONS: Holmium laser enucleation is an effective, safe procedure for large prostatic adenomas with significantly lower morbidity, catheterization duration and length of stay. Performing holmium laser enucleation for large adenomas requires experience. Stress incontinence was seen frequently with laser but was short-term and self-limited. Holmium laser enucleation is a new procedure, and as experience and expertise increase, it may become an attractive alternative to open prostatectomy for patients with large prostate adenomas.     

Fibrous contracture of bladder neck: cause, prevention, and treatment.

Through a retrospective study of bladder neck contracture it was found that bladder neck resection and incision were equally effective for treatment of postoperative bladder neck contractures. It was also found that incising the bladder neck at the end of transurethral resection of the prostate (TURP) did not cause vesicoureteral reflux and did not improve the incidence of postoperative bladder neck contracture.     

Suprapubic endoscopic vesical neck suspension.

Experience with 20 endoscopic vesical neck suspensions (Stamey procedure) is compared to 20 matched anterior cystourethropexies (Marshall-Marchetti-Krantz procedure) performed by the same staff. The present procedure is a transvaginal vesical neck suspension, described in 1959 by Pereyra, modified in 1973 by Stamey and further modified in 1975 by Mason. The long-term success rate for relief of urinary stress incontinence was 90 per cent with either procedure. Advantages and disadvantages of the endoscopic vesical neck suspension are discussed.     

Evaluation and treatment of dyssynergic bladder neck obstruction Is synchronous pressure-flow cystourethrography necessary?

Eighteen male patients underwent unilateral bladder neck incision for relief of bladder neck obstruction. The presence of obstruction was determined by clinical symptoms, residual urine, and uroflowmetry only. The decision to perform bladder neck incision was based on the typical endoseopic appearance of the prostatic urethra and bladder neck. Sixteen of 18 patients (89 per cent) had normal postoperative uroflowmetry. Subjectively, all patients judged themselves improved by the procedure. In those patients who are judged to be obstructed by clinical symptoms and uroflowmetry, dyssynergic bladder neck obstruction may be diagnosed by classic endoscopic findings rather than the routine use of synchronous pressure flow cystourethrography.     

A comparison of endoscopic suspension of the vesical neck versus anterior urethropexy for the treatment of stress urinary incontinence

Endoscopic suspension of the vesical neck has been reported to be as effective as anterior urethropexy in the treatment of female stress urinary incontinence. We compared our first 29 patients treated with endoscopic suspension of the vesical neck between 1982 and 1985 to our last 21 patients treated with anterior urethropexy between 1979 and 1985. Both groups were comparable in regard to age, parity, duration of symptoms and previous surgery for stress urinary incontinence. All patients underwent thorough preoperative urodynamic testing. Endoscopic suspension of the vesical neck successfully cured stress urinary incontinence in 26 patients (90 per cent), while anterior urethropexy resolved the incontinence in 20 (95 per cent). Of the 3 failures of endoscopic suspension 2 probably were related to technique or material failure. Hospitalization was reduced for endoscopic suspension versus anterior urethropexy (mean 4.04 versus 6.00 days, respectively). The most common complication after endoscopic suspension of the vesical neck was transient urinary retention (34 per cent). We conclude that endoscopic suspension of the vesical neck is an effective method to treat stress urinary incontinence, and that it also reduces hospital stay and postoperative recovery.     

Vesical neck reconstruction in patients with epispadias-exstrophy

Vesical neck reconstruction was performed in 50 male and 12 female patients with the epispadias-exstrophy complex. Of these patients 45 had epispadias and 17 had classical exstrophy. Patient age ranged from 3 to 27 years, with a mean age of 12.6 years. Followup after vesical neck reconstruction averaged 11.6 years. Of the 45 patients with epispadias 35 (78 per cent) and of the 17 with bladder exstrophy 13 (76 per cent) are continent, for an over-all continence rate of 77 per cent. An adequate bladder capacity was one of the most important determinants of continence. In 11 patients with a small capacity or poorly compliant bladder augmentation cystoplasty was combined with vesical neck reconstruction to increase vesical capacity and to produce complete urinary continence.     

Endoscopic suspension of vesical neck for urinary incontinence*

Surgically curable urinary incontinence in women is achieved by restoration of the vesical neck from a dependent position in the pelvis to one high behind the symphysis pubis. Endoscopic suspension, which accomplishes this by elevating the internal vesical neck on both sides with two permanent buttressed nylon loops is effective for correcting primary or recurrent stress urinary incontinence and even total incontinence in over 90 per cent of patients. Technical advantages over retropubic vesical neck suspensions include less postoperative morbidity, functional measurements and anatomic visualization of a restored vesical neck during the procedure, easy access to the surgically difficult pelvis, and simultaneous repair of significant rectoceles or substantial cystoceles through the same operative field.     

膀胱移行细胞癌伴前列腺癌的诊断与治疗

目的　提高膀胱移行细胞癌伴前列腺癌的诊治水平。　方法　对 8例膀胱移行细胞癌伴前列腺癌患者的临床资料进行分析。　结果　 8例术前均经膀胱镜检查及活检病理证实为膀胱移行细胞癌。 7例经直肠前列腺穿刺活检确诊前列腺癌 ,1例为前列腺增生症 ,行膀胱前列腺全切术后病理证实为前列腺癌。 4例行经尿道膀胱肿瘤电切及双侧睾丸切除术 ,术后使用丝裂霉素或BCG等膀胱灌注及氟他胺内分泌治疗。 1例行膀胱前列腺全切加回肠膀胱术。 8例中 2例失访 ,3例因多发性转移 ,术后存活 <1年 ,3例行根治性膀胱前列腺全切术 ,术后随访 1.5～ 4.0年 ,经胸片、CT、同位素和PSA等检查未见肿瘤复发或转移。　结论　血清PSA测定、前列腺直肠指诊、经直肠前列腺B超检查、活检及膀胱镜检查是诊断膀胱移行细胞癌伴前列腺腺癌的主要方法 ,根治性膀胱前列腺切除是影响预后的重要因素     

经尿道前列腺电切术后发生膀胱颈挛缩的条件logistic回归分析

目的对经尿道前列腺电切术(TURP)后发生膀胱颈挛缩(BNC)的各种因素进行多元回归分析,探寻主要影响因素。方法对2009年1月至2013年4月在我院泌尿外科接受TURP术治疗的前列腺增生患者812例进行随访,发现TURP术后的BNC患者,并选择同期内在我院泌尿外科行TURP术,术后1年内未出现BNC的患者进行配对,进行条件logistic回归分析。结果术前前列腺重量、单位时间切除重量、电凝切开深度这3个因素进入到多元回归方程,OR值分别为2.519、3.374、1.420。结论术前前列腺重量、单位时间切除重量、电凝切开深度是影响TURP术后BNC发生的主要因素,临床中应重视这些风险因素的参考价值,提高术者的手术操作技巧、术后对患者密切随访和及时处理是降低这种并发症的有效措施。     

经尿道前列腺电切术后膀胱颈挛缩17例诊治分析

目的探讨经尿道前列腺电切术(TURP)后膀胱颈挛缩的手术方法和预防措施。方法对17例膀胱颈挛缩患者临床资料进行回顾性分析。结果经尿道行残留前列腺组织电切术或先用冷刀切开颈部后换用电切刀切除瘢痕组织,术后3个月随访,17例患者症状均改善或消失。结论经尿道腔内治疗TURP术后膀胱颈挛缩是一种安全有效的方法。     

Transitional cell carcinoma of the prostate in cystoprostatectomy specimens removed for bladder cancer

Specimens from 84 radical cystectomies for bladder carcinoma performed between January 1984 and July 1986 were reviewed to characterize the involvement of the prostate with transitional cell carcinoma. Whole-mount sectioning of the prostate was performed at 4 mm. intervals and processed in the same manner as radical prostatectomy specimens. A total of 36 patients (43 per cent) had transitional cell carcinoma of the prostate: 94 per cent of these had prostatic urethra involvement and 6 per cent had a normal prostatic urethra but transitional cell carcinoma was present in the periurethral structures. In situ prostatic duct or acini, ejaculatory duct and seminal vesicle involvement occurred, respectively, in 67, 8 and 17 per cent of the patients with prostatic involvement. Of the patients with prostatic involvement 39 per cent had stromal invasion (22 per cent focal and 17 per cent diffuse invasion). The incidence of carcinoma in situ of the bladder neck or trigone (59 per cent), previous intravesical chemotherapy (59 per cent) and ureteral carcinoma (79 per cent) was significantly increased in patients with prostatic involvement. In patients with carcinoma in situ of the trigone or bladder neck, or in whom previous intravesical chemotherapy treatments have failed prostatic involvement should be suspected so that this disease can be detected before stromal invasion occurs.