Posterior Bladder Research Articles

Flexible Cystoscopy and Holmium:Yttrium Aluminum Garnet Laser Ablation for Recurrent Nonmuscle Invasive Bladder Carcinoma Under Local Anesthesia

The management of recurrent nonmuscle invasive bladder cancer (NMIBC) post-transurethral resection has been based around electrocautery techniques, either under local or general anesthetic. We determine the long-term outcome of the management of NMIBC recurrences treated with Holmium:Yttrium Aluminum Garnet (Ho:YAG) laser ablation under local anesthetic with a flexible cystoscope. We performed a prospective analysis of 151 consecutive patients, undergoing treatment of 444 tumors, between 2006 and 2011 in a University Teaching Hospital. Median follow-up was 24 months (0-58 months). The primary outcome was local, on-site recurrence rates of NMIBC. The secondary outcome measure included off-site recurrence rates, complications, pain perception, and patient satisfaction. Local, on-site recurrence rates after first treatment for all NMIBC disease were 10%. In patients with low risk NMIBC (G1/2, Ta), this reduced to around 4% post laser treatment. Higher recurrence rates (14%) were seen in those with high-grade (G3, T1) disease. Treatment was more successful with disease around the trigone, posterior and lateral bladder walls, with a significantly higher risk of recurrence for tumor around the ureteric orifice. The median time to local recurrence was 12 months and off-site recurrence was 25 months. Complication rates were low: dysuria (4.2%), frequency (1.5%), and hematuria (1.9%), with no episodes of bladder perforation. Visual analog pain scores were low, mean score 1 (range 0-7). The overall patient satisfaction was 100%. Flexible cystoscopy and Ho:YAG laser therapy should be considered as a first line treatment option for the management of recurrence in low-grade NMIBC (G1/2, Ta/1) throughout the bladder, except around the ureteric orifices. For those with high-grade disease (G3), the recurrences rates are increased, but the procedure still offers an acceptable recurrence rate. It provides good local disease control, low complications, patient acceptability and tolerance.

Recurrence and complications after transperineal bulboprostatic anastomosis for posterior urethral strictures resulting from pelvic fracture: a retrospective study from a urethral referral centre

To describe the complications of transperineal end-to-end anastomotic urethroplasty in patients with posterior urethral strictures resulting from pelvic fracture. A total of 573 patients, who underwent bulboprostatic anastomosis for posterior urethral strictures, were enrolled in this study. Distraction defects were measured using retrograde urethrography combined with voiding cysto-urethrography. All patients underwent perineal excision and primary anastomotic urethroplasty. The urethroplasty was considered successful if the patient was free of stricture-related obstruction and did not require any further intervention. The degree of stress incontinence was assessed daily by pad testing. The prevalence of pre- and postoperative sexual disorders was investigated using the International Index of Erectile Function-5 questionnaire. Of 573 bulboprostatic anastomosis procedures performed, 504 (88%) were successful and 69 (12%) were not successful. The mean (sd) maximum urinary flow rate, assessed by uroflowmetry 4 weeks after surgery, was 20.52 (5.1) mL/s. Intraoperative rectal injury was repaired primarily in 28 cases. Recurrence of urethral strictures was observed in 10 (1.7%) patients during the first 6 months after surgery, and in 45 patients from 6 months to 1 year. All of these patients underwent re-operation. Twenty-four (4.2%) patients had mild urge incontinence and 28 (4.9%) had mild stress incontinence. Erectile dysfunction (ED) was present in two (<0.1%) patients before trauma and in 487 (85%) patients after trauma. There was no statistical difference between the incidences of preoperative and postoperative ED (85 vs 86%, P > 0.05). Nine (1%) patients were found to have false passage between the posterior urethra and bladder neck. The majority of complications associated with transperineal bulboprostatic anastomosis can be avoided as long as meticulous preoperative evaluation to define the anatomy and careful intra-operative manipulation are ensured.

English

Bladder exstrophy-epispadias complex is a rare congenital anomaly. A higher occurrence in males compared to females is observed. It occurs due to failure of the abdominal wall closure during fetal development and results in protrusion of the posterior bladder wall through the lower abdominal wall. It involves a spectrum of anomalies of the lower abdominal wall, bladder, anterior bony pelvis and external genitalia. Here, we report a case of antenatal diagnosis of bladder exostrophy –epispadias complex in a seven months pregnant patient who came to us for routine antenatal sonography. On fetal MRI, our findings were confirmed. Patient was followed and normal vaginal delivery was done.

SU‐E‐T‐189: A Protocol for 3D IMRT Quality Assurance of Prostate Radiotherapy

Purpose: Define a set of statistical parameters and plan structures that will characterize the pass/fail criteria for a 3D prostate pre‐treatment IMRT quality assurance protocol. Methods: For this study, 3D IMRT QA measurements were performed on thirteen IMRT prostate patients. All plans were for an initial treatment course to the prostate and the seminal vesicles with prescription dose of 45Gy, and planned with step‐and‐shoot IMRT. All patients plans passed traditional QA methods, including point measurement with ion chamber and 2D gamma analysis at 3mm/3%. A total of 75 3D IMRT QA measurements were performed on all patients, on different days and on different beam matched linear accelerators. IBA COMPASS system was used for 3D QA measurements. For each patient, nine structures of interest were selected: femoral heads, two planning target volumes (PTV1, PTV2), prostate, seminal vesicles, anterior and posterior rectal wall and bladder. For each structure the following statistical parameters were evaluated: average dose, 3D gamma test, volume at 4% and 6% difference, and volume that receives between 5%‐105% of the prescription dose. Two QA protocols are proposed, a conservative with pass/fail QA thresholds the maximum of these 75 passing measurements; standard protocol with pass/fail QA threshold value at the maximum of the 75 measurements +50% increase. Results: Out of the 153 statistical parameters investigated, 65 were excluded from the QA protocol. The reason is that their values were constant for all 75 measurements. Assessment of the validity of the conservative protocol and standard protocol are ongoing. Conclusion: 3D IMRT QA is a powerful and versatile tool for pre‐treatment prostate IMRT QA, with ability to perform variety of statistical tests and overlay dose and anatomy. However, because 3D QA provides more information than single ion chamber measurement and/or 2D gamma analysis, a protocol is needed to establish pass/fail thresholds.

Robot-assisted Laparoscopic Mitrofanoff Appendicovesicostomy Technique and Outcomes of Extravesical and Intravesical Approaches

BackgroundWith growing experience in pediatric robotic surgery, select centers are now performing robot-assisted, laparoscopic Mitrofanoff appendicovesicostomy (RALMA). ObjectiveWe present our technique and outcomes of RALMA with or without enterocystoplasties and compare stomal outcomes between two different approaches of the appendicovesical anastomosis: an extravesical (EV) anterior bladder approach and an intravesical (IV) posterior bladder approach. Design, setting, and participantsData from 18 children who have undergone RALMA since 2008 were retrospectively reviewed. RALMA was performed by one surgeon in an academic setting. Surgical procedureThe appendix was anastomosed on the posterior wall of the bladder intravesically when concomitant enterocystoplasty was done. Otherwise, the appendix was anastomosed extravesically on the anterior wall of the bladder. Outcome measurements and statistical analysisThe primary outcome measured was the overall continence rate. Secondary outcomes included the overall complication rate and stomal complications. Results and limitationsThe entire cohort included 18 patients (10 IV, 8 EV). The mean overall operative time was 494.1min. The mean overall length of hospitalization was 5.2 d. There were five immediate, postoperative complications (all Clavien grade 1): three postoperative ilea, one stomal site infection, and one clogged suprapubic catheter. Median follow-up was 24.2 mo. The overall stomal continence rate was 94.4%. One patient from the IV group required dextranomer/hyaluronic acid copolymer for stomal incontinence. Among the eight patients in the EV cohort, there was one stomal complication of stomal stenosis (Clavien grade 1). Among the 10 patients in the IV cohort, there were two stomal complications requiring revisions (both Clavien grade 3): parastomal hernia and stomal stenosis. Limitations of the study include retrospective design, small number of patients, and lack of direct comparison of approaches given the nature of the surgery. ConclusionsOur updated outcomes of RALMA with or without enterocystoplasty continue to be encouraging, with a 94.4% continence rate. We believe that anterior EV reimplantation is a feasible option in isolated RALMA.

V573 ROBOTIC EXCISION OF THE SYMPTOMATIC PROSTATIC UTRICLE: AN IDEAL APPLICATION OF TECHNOLOGY

You have accessJournal of UrologyPediatrics1 Apr 2013V573 ROBOTIC EXCISION OF THE SYMPTOMATIC PROSTATIC UTRICLE: AN IDEAL APPLICATION OF TECHNOLOGY Janelle Fox, Omaya Banihani, and Glenn Cannon Janelle FoxJanelle Fox Pittsburgh, PA More articles by this author , Omaya BanihaniOmaya Banihani Pittsburgh, PA More articles by this author , and Glenn CannonGlenn Cannon Pittsburgh, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1969AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic excision of symptomatic prostatic utricles has been suggested as the ideal approach for the narrow pediatric male pelvis. It obviates the need for trigone splitting with the transvesical approach, rectum splitting with posterior sagittal approaches, or incomplete excision with perineal approaches. We present a case of robotic assisted laparoscopic excision of a symptomatic prostatic utricle in a child with mixed gonadal dysgenesis. METHODS A 4 year old boy with history of scrotal hypospadias and 45XO/46XY karyotype presented with recurrent urinary tract infections. His surgical history was remarkable for streak gonadectomy and tubularized preputial island flap urethroplasty in infancy. VCUG revealed a patent hypospadias repair, no significant diverticulum and large prostatic utricle. Cystoscopy confirmed an infected utricle with long, narrow neck. After appropriate antibiotic course, surgical excision of the utricle was planned. RESULTS Initial cystoscopy allowed placement of a 4Fr Fogarty catheter over a wire into the utricle and another 8Fr catheter within the bladder. Using the da Vinci® Si Surgical System, a 3-port pelvic approach with 5mm assistant port was chosen with patient in dorsal lithotomy position. The peritoneum was incised over the posterior bladder wall just above the catheter impression within the prostatic utricle. Retrovesical dissection was completed surrounding the utricle, preserving the posterior peritoneal reflection. Vasa were not associated with the utricle. The utricle stalk was suture ligated and transected near the pelvic floor at the level of prostatic urethra. Procedure duration was 182 minutes including cystoscopy, with minimal blood loss and hospital discharge on post op day 1. VCUG was performed one week postoperatively, confirming obliteration of the utricle cavity and the urethral catheter was removed. The patient has been free of urinary tract infection for one year of follow up. CONCLUSIONS Robotic-assisted laparoscopic utricle excision offers similar safety and efficacy to a pure laparoscopic approach. Since robotic assistance enhances laparoscopic magnification, robotic utricle excision may also improve identification of the ureters, associated Wolffian structures or anatomic variants. Combined with its advantage in a narrow pelvis, we feel robotic assistance for utricle excision is an ideal application of medical technology. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e235 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Janelle Fox Pittsburgh, PA More articles by this author Omaya Banihani Pittsburgh, PA More articles by this author Glenn Cannon Pittsburgh, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V1858 PROSTATE-SPARING RADICAL CYSTECTOMY WITH PROSTATIC CAPSULE AND VASA DEFERENTIA SPARING BY MEANS OF MILLIN PROSTATECTOMY

You have accessJournal of UrologyBladder Oncology1 Apr 2013V1858 PROSTATE-SPARING RADICAL CYSTECTOMY WITH PROSTATIC CAPSULE AND VASA DEFERENTIA SPARING BY MEANS OF MILLIN PROSTATECTOMY Rafael Sanchez-Salas, Petr Macek, Francois Rozet, Eric Barret, Marc Galiano, Luca Lunelli, and Xavier Cathelineau Rafael Sanchez-SalasRafael Sanchez-Salas Paris, France More articles by this author , Petr MacekPetr Macek Paris, France More articles by this author , Francois RozetFrancois Rozet Paris, France More articles by this author , Eric BarretEric Barret Paris, France More articles by this author , Marc GalianoMarc Galiano Paris, France More articles by this author , Luca LunelliLuca Lunelli Paris, France More articles by this author , and Xavier CathelineauXavier Cathelineau Paris, France More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2277AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy (RC) is a major surgery with risks including incontinence, erectile dysfunction and loss of ejaculations. There are various approach how to improve functional results. One of the proposed methods is prostate sparing by various techniques. The objective is to present the technique of prostate-sparing RC (PSRC) with prostatic capsule and vasa deferentia sparing by means of Millin prostatectomy. METHODS To describe the technique we present a case of 63 year healthy male with T2 N0 M0 urothelial bladder cancer located at the posterior bladder wall. His erectile function was normal and he strongly wished to maintain ejaculation. Following a discussion on management options a PSRC was chosen. His PSA was 1,67 and due to the type of treatment 12-core prostate biopsy was performed with negative result. He underwent 2 courses of neoadjuvant chemotherapy and robot-assisted PSRC was performed. RESULTS We use transperitoneal approach in Trendelenburg position. Bilateral extended pelvic lymph node dissection was performed initially with care not to divide vasa deferentia. Once completed posterior peritoneum is open above the tips of seminal vesicles a dissection is done laterally to isolate vas deference and ureters. Distal ureteral margins were sent for frozen section. Dissection continues posteriorly between vasa and seminal vesicles to identify the base of prostate. Then anterior incision of prostatic capsule is done and enucleation of adenoma is started. At the level of uretra catheter is clipped and divided. Afterwards the bladder is detached laterally to identify the sides of prostate. Opening of prostatic capsule is done posteriorly, extended ventrally on both sides and enucleation of adenoma is completed. The whole specimen is removed in the bag via small midline incision, which is also used for extracorporeal ileal neobladder formation with uretero-neobladder anastomosis as usually. Pouch is placed back to pelvis, laparotomy closed and robotic system redocked. Anastomosis of neobladder to the prostatic capsule is done with running 3/0 V-loc stitches and 2 Redon drains are placed. Final histology was pT0 pN0 (26/0) for bladder and no cancer in the prostate. Three weeks later the patients was continent and had penile tumescence. CONCLUSIONS PSRC is an alternative for highly selected patients who wish to maintain erectile function and/or ejaculation.Robotic?assistance may be beneficial for patient and surgeon. The surgeon needs to be familiar with the technique and adenoma enucleation may be more difficult in small prostates. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e762 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafael Sanchez-Salas Paris, France More articles by this author Petr Macek Paris, France More articles by this author Francois Rozet Paris, France More articles by this author Eric Barret Paris, France More articles by this author Marc Galiano Paris, France More articles by this author Luca Lunelli Paris, France More articles by this author Xavier Cathelineau Paris, France More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Measurements of the lower uterine segment during gestation

To establish normal values for the lower uterine segment (LUS) thickness and to recognize factors that may affect these values. In this cross-sectional study, we measured the LUS thickness in women between 11 and 41 weeks gestation. Women with placental abnormalities and fetal anomalies were excluded. Fetal weight, location of placental implantation, and cervical length were estimated. The LUS was examined to identify the thinnest zone and evaluated using the transvaginal approach with an empty urinary bladder. Full LUS thickness was measured with a caliper at the inner surface of the posterior bladder wall and another caliper at the interface between the amniotic fluid and the decidua. The myometrium was measured with the first caliper at the interface between the amniotic fluid and the deciduas and the second between the bladder wall and the myometrium. Normal values for the LUS were established throughout gestation, and correlations between the LUS gestational age, fetal weight, previous cesarean section, and other parameters were examined. Overall, 350 women were included in our study. Median parity was 1 (0-6) and the majority (62%, 218/350) of women have not had a previous cesarean section. The LUS thickness inversely correlated with gestational week (Pearson's r = -0.11, p < 0.03). When stratifying the linear regression model to women with and without a history of a previous cesarean section, it was demonstrated that gestational age was moderately correlated with LUS only in the second group of patients (Pearson's r = -0.16, p = 0.1 and Pearson's r = -0.47, p < 0.0001, respectively). During the post term period, patients who had had a previous cesarean section had significantly thinner LUS compared with patients who had not had a previous cesarean section (46 mm ± 20 versus 59 mm ± 20, p = 0.002, respectively). Neither parity nor the number of previous cesarean sections were found to correlate with the thickness of the LUS (p > 0.05). Multivariate linear regression (R(2) = 0.215, F(2, 63) = 9.021, p < 0.001) demonstrated that both gestational week (β = -0.13, p < 0.04) and cesarean section (β = -0.01, p < 0.0001) were independent factors associated with the thickness of the LUS; for every 1 week increase in gestational week, there was a 1.3 mm decrease in the total thickness of the LUS CONCLUSIONS: We have established reference ranges for LUS thickness throughout gestation. The LUS thickness decreases throughout gestation in singleton pregnancies and is significantly thinner in postterm period pregnant women with a previous cesarean section.

Congenital Posterior Urethral Diverticulum in a Male Child Case Report

Bladder neck and posterior urethra are common sites for obstructive uropathy in children. Diverticula of posterior urethra are rare cause of obstruction in children. A six year old boy presented with features of bladder outflow obstruction since birth. Ultrasound findings were suggestive of posterior urethral valve. Micturating cystourethrogram and endoscopic examinations revealed posterior urethral diverticulum which was placed dorsally. Diverticulectomy and reconstruction of urethra was performed by midline perineal incision. This report emphasizes that a posterior urethral diverticulum may be considered in those cases where features are suggestive of posterior urethral valve bladder outflow obstruction. DOI: http://dx.doi.org/10.3126/jnps.v32i3.5914 J. Nepal Paediatr. SocVol.32(3) 2012 257-258

The use of electromagnetic transponder beacons to reduce planning target volume (PTV) margins in post-prostatectomy patients undergoing adjuvant or salvage radiation therapy.

233 Background: We determined necessary PTV margins when beacons are used to localize the prostatic fossa in post-prostatectomy patients. We hypothesized beacon localization would allow for decreased PTV margins and increased normal tissue sparing. Methods: 10 patients requiring post-prostatectomy radiation were treated on this IRB-approved prospective study. Each patient had 3 beacons placed in the prostatic fossa. Daily radiation was localized by beacons and a cone-beam CT (CBCT) taken for analysis. By measuring differences between the treated clinical target volume (CTV) and relevant anatomy on 5 equally-spaced axial CT slices we calculated necessary PTV margins for each fraction. We then auto-fused each CBCT scan with the treatment planning scan, recorded the shifts incurred, and repeated our measurements, representing a hypothetical CBCT - localized treatment. We report a PTV margin for each technique that would cover the CTV during 90% of all 304 fractions analyzed. We also used intra-fraction motion data to produce a worst-case estimate of required PTV bladder margins. Results: The average shifts from the beacon to CBCT- localized isocenter were 2.9, 3.2, 1.0 mm and 0.58 degrees in the vertical, longitudinal, lateral, and rotational planes, respectively. Necessary PTV margins for beacon and CBCT localization are listed in the Table. Conclusions: Beacon localization “attaches” the CTV to the bladder, allowing a decrease in PTV margin or the amount of posterior bladder included in the CTV. This could lead to decreased rates of bladder toxicity. Clinical trial information: NCT01624623. [Table: see text]

Comparison of musculoskeletal anatomic relationships, determined by magnetic resonance imaging, in postpubertal female patients with and without classic bladder exstrophy

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Several studies in the paediatric literature have characterized the pelvic musculoskeletal anatomy of infants and children with bladder exstrophy using MRI and three-dimensional CT. The pelvic floor anatomy of female patients with bladder exstrophy who have undergone somatic growth and puberty is less well described. This study uses MRI to characterize comprehensively the pelvic anatomy of postpubertal females with classic bladder exstrophy by measuring 15 pelvic floor variables previously described in younger children with bladder exstrophy. To characterize pelvic musculoskeletal anatomy in postpubertal females with classic bladder exstrophy, and to compare this with females without bladder exstrophy. The authors reviewed the medical records of all females in our institutional review board-approved bladder exstrophy database of 1078 patients and identified those with classic bladder exstrophy who underwent pelvic magnetic resonance imaging (MRI) after the age of 12 years. Indications for MRI included haematuria, adnexal lesion, perineal fistula, non-pelvic cancer staging, abdominal wall hernia and vaginal stenosis. Age- and race-matched female patients without exstrophy who underwent MRI evaluation for similar indications were included for comparison. The MRI protocol included axial, sagittal and coronal T1- and/or T2-weighted imaging. The study included 30 patients with a median (range) age of 22.5 (12-55) years at time of MRI. Ten patients had bladder exstrophy while 20 control patients did not. A smaller percentage of levator ani was located in the anterior compartment of the pelvis in patients with bladder exstrophy compared with controls. The iliac wing angle, puborectalis angle, ileococcygeous angle, levator ani width, symphyseal diastasis, erectile body diastasis, posterior bladder neck distance and posterior anal distance was greater in patients with bladder exstrophy than in those without. The ischial angle and obturator internus angle were narrower in patients with bladder exstrophy than in those without, and there was no significant difference between levator ani surface area, sacral anal angle, sacral bladder neck angle and bladder neck erectile body distance between the two patient groups. In postpubertal females with bladder exstrophy, significant deviations from normal pelvimetry exist, including posterior location of the majority of the levator ani muscle, a wider ileococcygeous angle and a wider symphyseal diastasis. These differences are similar to those described in previous comparisons of younger children with bladder exstrophy and control children.

Uterine Rupture with Massive Late Postpartum Hemorrhage due to Placenta Percreta Left Partially In Situ

Placental adhesive disorders involve the growth of placental tissue into or through the uterine wall. Among these disorders, placenta percreta is the rarest one. However, it may cause significant complications. This report aimed to report a neglected patient with placenta percreta who developed uterine rupture with life-threatening late postpartum intra-abdominal hemorrhage. On admission, the patient had acute abdomen with moderate abdominal distention and was subjected to emergency laparotomy. A full-thickness defect of the anterior uterine wall involving the hysterotomy site was seen. Placental tissues occupied both sides of the incision and posterior bladder wall was also invaded by placenta. Total abdominal hysterectomy with partial resection of the posterior bladder wall was performed.

Bladder Actinomycosis: Mimicking Tumour

Actinomycosis is a chronic, granulomatous disease caused by the actinomyces species, most commonly, Actinomyces israelii. Primary actinomycosis of the bladder is rare and is usually associated with abdomino-pelvic infection and prolonged use of Intrauterine Device (IUD). On imaging, it can often be mistaken for a malignancy. We report a case of a 55-year-old female with weight loss, anaemia and chronic pelvic discharge with a history of a retained IUD. An initial Computerized Tomography (CT) revealed an adnexal mass that was pelvically resected. A rigid cystoscopy was then performed and an incidental posterior bladder wall mass revealed actinomycosis

Spontaneous Bladder Perforation in an Infant Neurogenic Bladder: Laparoscopic Management

Spontaneous bladder perforation is an uncommon event in childhood. It is usually associated with bladder augmentation. We are presenting a case of bladder rupture in an infant with neurogenic bladder without prior bladder surgery. Three days after lipomyelomeningocele excision the patient showed signs and symptoms of acute abdomen. The ultrasound exploration revealed significant amount of intraperitoneal free fluid and therefore a laparoscopic exploration was performed. A posterior bladder rupture was diagnosed and repaired laparoscopically. Currently, being 3 years old, she keeps successfully dry with clean intermittent catheterization. Neurogenic bladder voiding function can change at any time of its evolution and lead to complications. Early diagnosis of spontaneous bladder rupture is of paramount importance, so it is essential to think about it in the differential diagnosis of acute abdomen.

Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position

Operative positions commonly used in urogenital surgeries when perineal exposure is required include the lithotomy and the exaggerated lithotomy positions (LPs), which expose patients to the risk of rhabdomyolysis. We report a patient with bladder outflow obstruction, benign prostatic hypertrophy and a very large bladder stone, which was removed with cystoscopy and cystolitholapaxy in the LP. The procedure was complicated by posterior bladder perforation and abdominal distention leading to prolonged surgery duration (5.5 h). The patient developed rhabdomyolysis and acute renal failure (ARF) without compartmental syndrome. On the other hand, there was a potential role of glycine solution, used for bladder irrigation, in the appearance of ARF. Overall, our case shows that rhabdomyolysis and ARF can develop in operative positions, and duration of surgery is the most important risk factor for such complications.

Facilitating 3D Image Guided Treatment Planning of Shielded Tandem and Ovoid-based, Gynecological Brachytherapy Utilizing MVCT

A drawback of tandem and ovoid (T&O) ICBT is exposure of the posterior bladder and anterior rectal walls to relatively high isodoses. To mitigate this effect, intra-ovoid shielding may be used to reduce dose to these OARs. However, metal artifacts present in images acquired via kVCT make anatomy segmentation and catheter localization difficult for the purpose of 3D treatment planning. We present a method that combines MVCT-based imaging and applicator modeling to increase the quality of 3D treatment plans for shielded T&O ICBT.

Endorectal Balloons in Postprostatectomy Radiation Therapy — Improved Stability of Clinical Target Volumes and Reduction of Geographical Miss

The clinical target volume (CTV) in post-prostatectomy radiation therapy is bounded in part by the anterior rectal wall and posterior bladder wall. Therefore, deformation of these organs and hence the target volume can result in potential geographical miss. We report on the impact of endorectal balloons (ERB) on post-prostatectomy CTV stability, and quantify the minimum margin expansions required to avoid geographical miss.

Dosimetric and Biological Impacts of Simultaneous Integrated Brachytherapy Boost (SIBB) Delivered via I125 Seeds Followed by External Beam Radiation Therapy (EBRT) on Prostate Cancer

To report the dosimetric and biological impacts of SIBB delivered via I125 seeds followed by EBRT on prostate cancer and normal tissue tolerance. This is a single institution retrospective study. From January 2000-2010; 125 patients with high risk prostate cancer underwent SIBB via I125 followed by EBRT. I125 was implanted on day 0 (D0) 3 weeks prior to EBRT. On day 21 (D21) and day (D58) post-implant the EBRT started and completed respectively. A dose of 50.4, at daily 1.8 Gy x 28, was delivered. The posterior bladder wall and anterior rectal wall were in the range of seeds (≤1 cm) and included in the PTV during EBRT were defined as bladder and rectum at risk. The linear-quadratic model was used to determine the biological equivalent dose (BED) for EBRT treatments using BED = nd [1+ (d/α/β)] and for low-dose-rate I125; BED = (R0/λ) {1+[R0 ⁄(μ+λ)(α/β)]} α/β of 1.86 and 3 Gy were applied for prostate cancer and normal tissue respectively. The BED values for treatments involving both implant and EBRT were calculated by adding the BEDs computed for each treatment. Heterogeneity correction for the I125 seeds (median number of seeds 40) was applied to determine the impact of seeds on dose computation. The calculated BED delivered via I125 alone were 112Gyα/β = 1.86 and 110 Gyα/β = 3 for prostate and normal tissue respectively. The computed BED for the combined modality without considering the SIBB were (112+99 = 211Gyα/β = 1.86) and (110+80 = 190Gyα/β = 3) for prostate and normal tissue respectively. SIBB dose was calculated based on the median dose/fx of 0.8Gy (0.6-1), delivered via I125 during EBRT. Therefore the dose delivered during the 28 days of EBRT was of median 2.6 (0.8+1.8) Gy/day (range 2.4-2.8). The total dose delivered via I125 seeds alone was 85Gy; specifically 31Gy [during Day0 to Day20 and 10 weekend days of EBRT] + 54Gy [≥Day59]. The total dose delivered from SIBB + EBRT [2.6 Gy/fx X 28] were 175Gyα/β = 1.86 and 136 Gy α/β = 3 to prostate and normal tissue respectively. Inclusion of SIBB resulted in 123% and 116% increase in prostate and normal tissue doses respectively. Heterogeneity correction for the seeds showed minor impact (±3%) on EBRT dose computation. With a median follow up of 7 years (2-12) the GU and GI RTOG toxicities grade ≤2 were 17% and 9% respectively with no grade ≥3 was reported. Extreme caution should be taken into consideration while integrating the I125 SSIB as it delivers significant extra-dose to the prostate and normal tissues. The tolerance of rectum and bladder should be revisited in further studies based on actual dose delivered, not planned. Heterogeneity correction for the seeds seems to be of minor impact ±3% on dose computation.

Flexible Cystoscope for Evaluating Pelvic Fracture Urethral Distraction Defects

Objective: To describe the value of flexible cystoscopy versus conventional urethrography (retrograde urethrography and cystourethrography) in diagnosing pelvic fracture urethral distraction defects (PFUDDs). Patients and Methods: Between May 2010 and June 2011, 120 male patients with PFUDDs were evaluated. In this study, all patients underwent conventional urethrography after admission. Flexible cystoscopy was also used for comparison, followed by conventional urethrography. The flexible cystoscope was introduced into the posterior urethra and the area was evaluated for the length of the proximal urethra and any possible fistulas, false passages, calculi or displacement of the posterior urethra. Results: Severe allergic reaction or obvious discomfort did not occur in any patients after conventional urethrography or flexible cystoscopy. By comparing the data obtained from flexible cystoscopy to those from conventional urethrography, no statistical difference was found in the measured length of the proximal posterior urethra (4.31 ± 2.28 vs. 4.02 ± 3.12, p > 0.05). However, the rate of detection in other abnormalities was higher in flexible cystoscopy than in conventional urethrography (48.3 vs. 10.8%, p < 0.05). Seventeen (14.2%), 9 (7.5%) and 32 (26.7%) patients were detected with fistula, false passage and calculus, respectively, according to flexible cystoscopy. In comparison, fistula, false passage and calculus were only observed in 2 (1.7%), 7 (5.8%) and 4 (3.3%) patients, respectively, through conventional urethrography imaging. Conclusions: Flexible cystoscopy is a valuable procedure in the evaluation of the posterior urethra and bladder neck, and in patients with urethral distraction defects before surgery. More details about fistulas, false passages, calculi and urethral defects could be obtained through this method.

Rare coexistence of placenta previa accreta and peritoneal adhesion: three-decade clinical observation

Peritoneal adhesion makes abdominal surgery difficult. The recent increase in cesarean section (CS) is considered a main culprit for increase of placenta previa accreta (PPA) (accreta, increata, or percreta), which usually requires cesarean hysterectomy (CH). A recent article in this journal demonstrated that of 247 patients with placenta previa, 12 (4.9 %) required hysterectomy; 11 out of 12 had histologically confirmed placenta accreta [1]. We have devised some measures for CH [2, 3], which I have also described in this journal [2]. Briefly, we avoid administering uterotonic agents after infant delivery [2] and we employ ‘‘double distal edge pickup’’ mass ligation to ligate the medial side of the incised uterus [2]. If the placenta invades the bladder, we, without separating the bladder, intentionally cut the bladder wall and remove the uterus with the posterior bladder wall kept adhering to the uterus [3]. Even with these techniques, CH for PPA is always challenging. If peritoneal adhesion exists, it will make this difficult surgery more difficult. Laparotomy including CS sometimes leads to peritoneal adhesion, which makes next CS difficult. Since PPA usually occurs in patients with previous CS, it is likely that peritoneal adhesion and PPA tend to coexist. This is contrary to my observation derived from my three-decade tertiary obstetric center practice. My observation is that PPA does not, or at least rarely, accompanies peritoneal adhesion. Fortunately, no patients had severe adhesion requiring its adhesiolysis. This is in stark contrast to both previous data and our own data. Previous reports indicated that adhesion requiring surgical intervention such as adhesiolysis occurred in approximately one quarter (21-27 %) [4, 5] in repeat CS. I have performed approximately 40 CH for PPA during three decades, with almost all having a previous history of CS. Although the detailed surgical data have been missing during three decades and adhesion was not scored, the uterus could be easily exteriorized without adhesiolysis in all patients. This indicated that no PPA patients had adhesion of more than stage 3, with stage 4 being the full mark, according to the Myers and Bennett adhesion staging system [4]. Usually stage 3 and 4 adhesion are referred to as ‘‘clinically significant’’ adhesion [4]. Thus, whereas approximately one quarter of repeat CS patients had significant adhesion [4, 5], no PPA patients had it even though almost all had a previous CS history. I examined the surgical records of patients who underwent repeat CS without current PPA from July to December 2011 in this institute. Excluding the patients with the abdominal surgery history other than CS and those under steroid administration, 64 patients received repeat CS. Although its degree was not staged [4], peritoneal adhesion was present in 47 % (30/64), with 13 % (8/64) requiring surgical intervention. The mechanism for this observation is unclear; however, decreased wound healing may, at least partly, account for this phenomenon. Not well-healed CS scar leads to insufficient decidualization, which results in trophoblasts invading the uterine muscle layers, causing PPA [6]. Thus, decreased wound healing is considered to be a possible culprit for PPA. Wound healing consists of several steps: inflammatory cell mobilization to the site, fibroblast mobilization, and finally proliferation and regeneration of the corresponding tissue. Peritoneal adhesion formation S. Matsubara (&) Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp