Long-term Urologic Complications Research Articles

Risk factors of video urodynamics and bladder management for long-term complications in patients with chronic spinal cord injury

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury.

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Pelvic Mass 21 Years after Total Hip Arthroplasty

Background. Long-term urologic complications after total hip arthroplasty are rare, and reports in the urologic literature are scant. We present a recent case and review the relevant literature. Case. A 77-year-old man was referred to the urology clinic for a single episode of gross painless hematuria, abnormal urine cytology, and pelvic mass. He had a significant smoking history. Surgical history included right total hip arthroplasty 21 years prior. Results. Pelvic ultrasound revealed a large mass abutting the right bladder wall. Subsequent computed tomography indicated that the mass was extrinsic to the bladder. Results of computed tomography-guided biopsy of the mass were consistent with foreign body granuloma. Surveillance imaging confirmed no growth or progression, and intervention was deferred. Conclusion. Long-term complications of total hip arthroplasty may present with signs and symptoms of urologic disease. Reports in the urologic literature are rare.

Penile Reconstruction with the Radial Forearm Flap: An Update

Many methods and many free or pedicled flaps have been used in phalloplasty. None of these techniques is able to completely fulfill the well described goals in penile reconstruction. Still, the radial forearm glap is currently the most frequently used flap and thus universally considered the gold standard. Since 1992, we have performed the largest series of 316 radial forearm phalloplasties to date performed by a single surgical team. From these extensive data we critically evaluate how this current supposed gold standard can meet the requirements of an ideal penile reconstruction. We assessed outcome parameters such as number of procedures to achieve complete functional result, aesthetic outcome, tactile and erogenous sensation, voiding, donor site morbidity, scrotoplasty and sexual intercourse. While currently no controlled randomized prospective studies are available to prove the radial forearm flap is truly the 'gold standard' in penile reconstruction, we believe that our retrospective data support the radial forearm phalloplasty as a very reliable technique for the creation of a normal looking penis and scrotum. While full functionality is achieved through a minimum of 2 procedures, the patients are always able to void standing, and in most cases to experience sexual satisfaction. The relative disadvantages of this technique are the residual scar on the forearm donor site, the rather high number of initial urinary fistulas, the potential for long-term urological complications and the need for a stiffener or erection prosthesis. From our experience, we strongly feel that a structured multi-disciplinary cooperation between the reconstructive-plastic surgeon and the urologist is an absolute requisite to obtain the best possible technical results.

Roux limb volvulus after pancreas transplantation: an unusual cause of pancreatic graft loss

Pancreas transplantation with enteric drainage avoids the long-term urological complications of bladder drainage. Increasing use of this technique raises the possibility of complications from the enteric reconstruction. This report describes a patient five yr after left-sided pancreas transplant with Roux-en-Y enteric drainage, presenting with abdominal pain, leukocytosis and radiological evidence of bowel obstruction. Exploration revealed a volvulus of the Roux limb as it passed through the mesocolon, with necrosis of the allograft duodenum and marked congestion of the pancreas. This is the first report of pancreas graft loss due to this entity, which should be recognized as an unusual cause of abdominal pain after pancreas transplantation. Potential bowel complications related to the sigmoid mesentery in left-sided pancreas transplantation are additional reasons for right-sided placement of the pancreas allograft.

Pancreas-Kidney Transplantations With Primary Bladder Drainage Followed by Enteric Conversion: Graft Survival and Outcomes

In the Leiden University Medical Centre, a two-step approach is routinely used in simultaneous pancreas-kidney (SPK) transplantations: primary bladder drainage (BD) followed by elective enteric conversion. The rationale for this approach is to prevent the short-term disadvantages of primary enteric drainage (intra-abdominal abscesses, pancreas graft loss) and the long-term urological complications related to bladder drainage. Aim of the present study is to evaluate survival and (urological) complications of this approach compared to enteric drainage (ED). Patient records of all 98 SPK transplantations in the period 1997-2004 were reviewed for complications during the initial hospitalization until 30 days after discharge, and to assess urological complications and graft survival until the last hospital visit. Median duration of follow-up was 4.3 years for pancreas graft survival, 4.7 years for kidney graft survival, and 4.8 years for patient survival. Patient survival was significantly better in BD patients than in ED patients (chi2=9.89 P<0.01). Pancreas graft survival was also better in BD patients after adjustment for the longer pancreas warm ischemia time in BD patients (P=0.05). The survival rates in our patient population seem higher than reported by the International Pancreas Transplant Registry, particularly in BD patients. Urological complications occurred in nine BD patients (10.3%), comparable to the rates reported for enteric-drained grafts. This two-step approach of SPK transplantation results in excellent survival rates, with urological complication rates comparable to those reported for enteric-drained grafts, and may thus be viewed as a safe and effective procedure of SPK transplantation.

Urologic function and urodynamic evaluation of urinary diversion (Rome pouch) over time in gynecologic cancers patients

Objective To describe the urologic late complications and urodynamics outcome adopting teniamyotomies technique to create a low-pressure reservoir using the cecum, ascending colon and proximal part of the transverse colon without detubularization (Rome pouch). Methods Twenty-eight consecutive patients affected by gynecological cancer and submitted urinary diversion with “Rome pouch” technique were included. After 3 and 12 months from the surgical procedure patients were submitted to urodynamic evaluation of the neobladders. Excretory urography was performed in all patient. Abdominal X-ray, serum electrolytes, creatinine and cultures of the reservoir are obtained during every visit. Long-term urologic complications were recorded. Patient quality of life was assessed using a 10 cm grade visual analog scale (VAS). Results Urodynamics performed 12 months postoperatively showed that the mean maximum reservoir capacity was 439.9 ± 58.9 cm H 2O. The mean reservoir pressure at maximum capacity was 19.2 ± 8.4 cm H 2O (no contractive wave during the filling in any patient). The mean maximum closure pressure in the efferent tube, at maximum capacity, was 88.8 ± 32.3 cm H 2O. Continence was excellent for 26 (93%) and 23 (92%) patients at 3 and 12 months respectively. A total of 9 (32%) and 6 (24%) patients suffered late complications at 3 and 12 months follow-up respectively. However only one patient with pouch leakage underwent surgical pouch revision. Conclusion Our experience demonstrated that Rome pouch creation with multiple teniamyotomies has good capacity with low internal pressure and good continence with a low rate of late urologic complications. Thus, comparing results to those of other continent pouch models, the Rome pouch technique represents a valid alternative.

Long-term urologic, orthopedic, and psychological outcome of posterior urethral rupture in children

Objectives To evaluate the long-term urologic, orthopedic, and psychological outcome of children after posterior urethral rupture (PUR) due to pelvic trauma. Methods We retrospectively reviewed the records of 49 children with PUR from 1986 to 2000. The long-term urologic results were determined by voiding function, continence, and erectile function. The orthopedic results were determined by pelvic radiography and a questionnaire. Psychiatric diagnoses were made using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria and the Structured Clinical Interview for DSM-IV Axis I Disorders. Results The mean follow-up was 12 years (range 4 to 17). The average age was 8 years at the time of the trauma and 20 years at the last follow-up. Urethral continuity was achieved in 97.9% of the children. Of the 49 patients, 19 had at least one urologic complication, 18 had orthopedic pathologic findings, and 21 had psychiatric diagnoses. The number of urologic procedures required (more than three), presence of long-term complications, and total number of hospitalizations (more than three) secondary to the injury significantly affected the development of a psychological disorder. Conclusions The results of our study have shown that posttraumatic PUR in children is associated with a significant rate of long-term complications. Nonoperative treatment of pediatric pelvic fractures associated with PUR has been quite successful. Repeated operations, the presence of long-term urologic complications, and frequent and long hospital stays result in serious attendant psychological problems. Therefore, careful and prolonged follow-up of posttraumatic urethral injury with a multidisciplinary approach is necessary to provide better outcomes and a better quality of physical and social life for these children.

Analysis of the long-term outcome of surgically corrected vesico-ureteric reflux.

To review patients who had vesico-ureteric reflux corrected surgically by ureteric reimplantation during childhood, and thus assess their long-term outcome. Between 1970 and 1979, 322 children underwent ureteric reimplantation; 100 (79 women and 21 men) were re-assessed and the long-term results evaluated using a questionnaire, a review of the patients' current medical records and an appointment in the outpatient clinic. The evaluation focused on the frequency of late urinary tract infections (UTIs), current renal function tests, related complications during pregnancy and the incidence of hypertension at least 20 years after surgery. Of the study group, 51% (66% of men and 47% of women) had no long-term urological complications. The incidence of UTIs was 43% in women and 24% in men, and of pyelonephritis 27% and 9.5%, respectively. Hypertension was detected in 6% of the patients during assessment. There were new renal scars, despite surgery, in 20% of the patients. Forty-seven women had been pregnant, 28% reporting UTIs during pregnancy. In 7% of 94 pregnancies the women also had pre-eclampsia and two women had transient gestational ureteric obstruction which required drainage. Renal functional tests were worse in one man and one woman who developed end-stage renal disease and had a renal transplant. This series shows that even patients who were treated successfully by ureteric reimplantation during childhood are prone to recurrent UTIs, progressive renal scarring, hypertension and complications during pregnancy. There is a need to establish a protocol for the long-term follow-up of such patients.

Urodynamic testing predicts long-term urological complications following simultaneous pancreas-kidney transplantation.

Combined pancreas-kidney transplantation is the treatment of choice for patients with type I diabetes mellitus associated with chronic renal failure. The introduction of the bladder drainage technique constituted a marked improvement of the surgical technique with a reduction of life-threatening complications. However, drainage of pancreatic secretions via the urinary bladder causes urological complications leading, in some cases, to cystoenteric conversion. We retrospectively analysed whether pre-operative urodynamic findings may predict the subsequent development of urological complications and influence the choice of exocrine secretion drainage. From 1987 to 1997, 39 bladder-drained simultaneous pancreas-kidney transplantations were performed in 16 men and 23 women with a mean age of 38.5 yr. All patients underwent a complete urological assessment prior to surgery, including medical history, physical examination, urethrocystography and urodynamic assessment. Twenty-eight patients are alive with a mean follow-up of 62 +/- 8 months. In 60% of cases, both kidney and pancreas remain functional. Seven patients experienced recurrent lower urinary tract infections. Six patients suffered from chemical urethritis (four men and two women) and six suffered from recurrent haematuria (blood transfusions were required in two patients). One patient had incrusted stones at the site of duodenal staples. Urological complications were mostly observed in the 22 patients (79%) with abnormal urodynamic characteristics (Relative risk: 5.1). Intravenous Somatostatin failed to definitively cure these complications in most cases. Seven patients (17%) (five with urethritis, two with haematuria) required cystoenteric conversion. Two patients developed post-operative ileal fistula, one cutaneous and one into the bladder. All urinary symptoms resolved in these seven patients. The frequency of specific urinary complications is high (28%) in bladder-drained simultaneous pancreas-kidney transplantation patients. These complications are statistically more frequent in the case of an abnormal pre-transplant urodynamic assessment.

Surgical treatment of low stage cervical carcinoma: Back to the old days?

Radical hysterectomies for the treatment of cervical carcinoma are being performed laparoscopically by some surgeons. Others combine the laparoscopic lymphadenectomy with a radical vaginal hysterectomy or a radical trachelectomy, like in the Schauta procedure. In this way the procedure resembles the AVRUEL-procedure (Abdominal Vaginal Radical Uterus Extirpation with transperitoneal Lymphadenectomy), as developed in 1957 by Sindram who combined the Wertheim and the Schauta procedure together with abdominal lymphadenectomy in one single operation. Because of the high complication rate in the form of voiding problems and sexual impairment caused by the Schauta part, this operation is no longer performed. In order to pay attention to the morbidity associated in the past with the combined abdomino-vaginal approach compared to the single abdominal approach, we reassembled the data of several large Dutch centers where patients were treated either by the AVRUEL or the abdominal radical hysterectomy.A total of 730 patients underwent an AVRUEL procedure, all carried out between 1957 and 1981. Fistulas occurred in 57 patients (7.8%), long-term urologic complications in 233 patients (32%), and sexual dysfunction in 71 (9.7%) were found. A total of 928 patients underwent an abdominal radical hysterectomy, of whom in 511 cases the complication rates have been described. Twelve fistulas occurred (2%), long-term micturition problems in 55 (10%), and sexual problems in 11 (2%). There was no difference in 5-year survival rates in both groups. From the abovementioned data it is clear, that returning to the old days in terms of a re-introduction of the Schauta procedure is not to be preferred. In order to conclude if the laparoscopically assisted radical vaginal hysterectomy or the trachelectomy are an improvement, they should be carried out according to clearly defined prospective protocols in which data can be compared to those of other techniques with special attention to late complications including micturition and sexual sequelae.

LONG-TERM UROLOGICAL COMPLICATIONS IN SURVIVORS YOUNGER THAN 15 MONTHS OF ADVANCED STAGE ABDOMINAL NEUROBLASTOMA

We evaluated the long-term urological complications in survivors of infant advanced stage abdominal neuroblastoma. The records of patients who presented during an 8-year period with surgical problems related to the kidney and who had survived advanced stage (IV and IV-S) neuroblastoma were reviewed. Of 7 patients identified 3 had complications of obstruction from retroperitoneal fibrosis and 4 had renal cell carcinoma. In the renal cell carcinoma group 3 patients had synchronous, multifocal, bilateral tumors and 1 had a tumor in a solitary kidney. Pathological examination of renal cell carcinoma revealed oncocytoidy with solid and papillary patterns. One patient underwent bilateral nephrectomy but in the remaining 3 renal preservation surgery was performed. All 7 patients have no progression of secondary complications 2 to 8 years after initial presentation. Survivors of advanced stage abdominal neuroblastoma may be predisposed to long-term urological complications well after initial diagnosis. Because of the risk of renal damage from obstruction secondary to retroperitoneal fibrosis, and the propensity to have renal cell carcinoma, close long-term followup using abdominal imaging is recommended.

LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: IS IT SAFE? ANALYSIS OF 69 CONSECUTIVE CASES AND COMPARISON TO OPEN NEPHRECTOMY

44 Introduction: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney transplant donation. Although a more rapid and less painful post-operative recovery has been reported for LDN, concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in transplant recipients secondary to ureteral trauma during LDN. Objective: To assess the results of LDN as compared to ODN, the feasibility and safety of LDN, and the incidence of delayed graft function and urologic complications in LDN kidneys post-transplant. Methods: Between 10/97 and 1/99, 69 LDN's were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These patients were compared to 50 ODN performed from 1/96 to 10/97.(Table)TableLDN procedures took significantly longer than ODN. However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. No patients undergoing successful LDN required epidural or PCA analgesia, while all ODN pts did. Of the 69 LDN procedures, a total of 64 (93%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for questionable vascular anatomy. 7 LDN pts had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery and 1 aortic injury). Open conversion was associated with large donor body habitus and/or obesity (4 of 5 pts > 90 kg). All patients made complete recoveries. All LDN kidneys functioned immediately post-transplant. We have observed 100% graft and patient survival in LDN transplant recipients. There have been no short or long-term urologic complications in this series. Conclusion: With increasing experience and standardization of technique, LDN is a safe and effective procedure. LDN patients have a rapid postoperative recovery and short hospital stay. Excellent initial graft function and long-term graft survival have been observed. With careful surgical technique, urologic complications can be avoided. LDN has become the preferred surgical approach performed by transplant surgeons for living kidney donation at our center.

Retrospective analysis of urologic complications in male patients with spinal cord injury managed with and without indwelling urinary catheters

To compare, in a retrospective fashion, the long-term urologic complications in male patients with spinal cord injury managed with and without indwelling urinary catheters. The records of 142 consecutive male patients with traumatic spinal cord injuries sustained between 1975 and 1985 (inclusive) were reviewed. Fifty-six patients were managed with indwelling urinary catheters, and 86 were managed without an indwelling catheter. Urinary complications were recorded for each patient under the following general subheadings: renal, urinary tract infection, stones, urethral, and other. In all, there were 95 complications in the noncatheterized group versus 202 in the catheterized group (P = 0.007). The catheterized group experienced significantly more problems with renal damage, recurrent urinary tract infection, stones, and urethral complications. Our study shows that elimination of indwelling urinary catheters in patients with spinal cord injury will significantly reduce the incidence of urinary tract complications and lead to better preservation of renal function.