Posterior Bladder Research Articles

Laparoscopic radical prostatectomy: transperitoneal anterior bladder approach versus transperitoneal pos-terior bladder approach

Objective To compare perioperative parameters, as well as the oncological and func-tional results, for laparoscopic radical prostatectomy (LRP) performed via the posterior bladder and anterior bladder approaches. Methods The recorded pre-, peri-, and postoperative parameters and complications, and evaluated the oncological and functional results were collected and compared be-tween the posterior bladder approach (n=25) and the anterior bladder approach (n=34). Results There were no significant differences regarding the preoperative characteristics of the two groups. The mean blood loss, complications, positive surgical margins, and continence showed no significant differences between the 2 groups at 3 and 6 months postoperatively. The mean operation time was sig-nificantly shorter in anterior bladder approach group (174.2±58. 0 min) than in posterior bladder ap-proach group (224. 8±66.7 rain), (P<0. 01). Also, the postoperative recovery time until discharge was 5.9 d in anterior bladder approach group, which was significantly shorter than in posterior bladder approach group (7.5 d) (P<0.05). Conclusion The anterior bladder approach yields shorter oper-ation time and postoperative recovery period than posterior bladder approach for LRP. Key words: Prostatic neoplasms; Carcinoma; Laparoscopes; Radical prostatectomy; Anterior or posterior approach

Carcinoma transicional de vejiga en adolescentes: un diagnóstico para tener en cuenta

Transitional cell carcinoma of the bladder has a high incidence in adults, but it is uncommon in children and adolescents. Hematuria is the most common symptom of presentation and vesical ecography the preferred diagnostic method. The diagnosis and treatment is performed with cystoscopy and endoscopic resection. We describe two patients: an 18 years old male, who presented with a pediculated tumor on the posterior bladder wall and a 15 years old female with a 1 cm long tumor on the posterior wall too; both were removed under endoscopic control. In both patients superficial transitional cell carcinoma was the final diagnosis and are disease free 3 and 5 years later. A review of the available literature was performed to clarify if this type of tumors must be considered malignant and try to define how long and by which way these patients must be controlled.

Posterior urethral valves with vesical calculus: A rare association

Posterior urethral valve and vesical calculus are individually among the most common causes of obstructive lower urinary complaints in children. There are very few reports of association between posterior urethral valves and bladder calculus. We report three such cases. This association of the vesical calculi with posterior urethral valves may lead to a delay in the diagnosis of the posterior urethral valves. The diagnosis of posterior urethral valves should be suspected in all children with vesical or urethral calculi who have persistence of symptoms even after removal of the calculi.

Controversias en la anatomía quirúrgica prostática. Revisión de la literarura

IntroductionRadical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria for mentioning structures related with radical prostatectomy Material and MethodWith the followings key words: “cavernosal nerves, prostatectomy, anatomy, neurovascular bundle” we search in Medline/PubMed database selecting papers fulfilling the search criteria. ConclusionsThe prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers´s fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them.

Mitrofanoff continent catheterizable conduits: Top down or bottom up?

During augmentation and Mitrofanoff procedures, conduits are usually implanted into the posterior bladder wall. Anatomical considerations may necessitate an anterior conduit. To compare the relative drainage efficiency in patients with posterior and anterior conduits, we studied their rates of bladder stone formation and urinary tract infection (UTI). A retrospective chart review identified exstrophy patients who underwent augmentation and Mitrofanoff between 1991 and 2003. Patients with 3 years or greater follow-up were included. Fifty-four patients fit this criterion, with a conduit implanted anteriorly (33) or posteriorly (21). We compared rates of bladder stone formation and UTI. Stomal revisions and the status of the bladder neck were also noted. Stone formation and UTI rates were higher in the anterior conduits, although only UTI showed a statistically significant difference. Patient demographics were similar between the two groups, including age and sex. The rates of stomal complications and the bladder neck status were also similar. Patients with anterior conduits had an increased risk of UTI and bladder stone formation compared to those with posterior conduits, although this was not significant in the case of bladder stone rate. This may indicate sub-optimal bladder drainage and should be addressed with careful preoperative counseling and close follow-up.

Comparisons of the responses of anterior and posterior human adult male bladder neck smooth muscle to in vitro stimulation

To evaluate differing methods of stimulation on strips of human bladder neck smooth muscle and compare muscle taken from the anterior and posterior aspects. Samples of adult human male bladder neck muscle were obtained from patients undergoing open radical prostatectomy. Muscle was taken from either the anterior or posterior (nine and six patients, respectively) aspects of the bladder neck. Muscle strips dissected from these samples were suspended in the Brading-Sibley organ bath. The strips were superfused with 100 mm KCl-enriched Krebs' solution for 4 min to determine viability. This allowed experimentation on 17 strips from the anterior aspect of the bladder neck and 13 from the posterior bladder neck. These remaining strips were then superfused either with various concentrations (x10(-7) to x10(-3)m) of carbachol or noradrenaline in Krebs' solution, for 15 s. A further set of strips (eight from anterior, six from posterior) was suspended and responses to electrical field stimulation (EFS) with varying parameters were measured. Each EFS experiment was repeated after a 15 min exposure to 10(-3)m atropine, and again after a 15 min exposure 10(-7)m tetrodotoxin (TTX). Tension responses produced in these series of experiments were measured using strain gauges and analysed using data acquisition software. Student's t-test was used for the statistical analysis. All muscle strips included in the study responded to EFS. The magnitude of this contraction is frequency dependent. The contractions were abolished by superfusion of the muscle strips with atropine. There was no further suppression of the contractile response on addition of TTX. Posterior bladder neck samples had a greater mean contractile response per unit mass than anterior strips at all frequencies of >1 Hz, and significantly more at 20 and 30 Hz. There was a concentration-dependent response in bladder neck contraction to carbachol but only in the strips from the anterior bladder neck at concentrations of <10(-3)m. Posterior bladder neck strips did not significantly contract upon application of carbachol. Similarly, there was a concentration-dependent response to noradrenaline. Responses to noradrenaline were not uniform around the bladder neck, but not significantly different. Carbachol was the more 'potent' stimulator in anterior smooth muscle strips, but again the differences between agonists were not statistically significant. These experiments show physiological variability around the circumference of the human male bladder neck. The posterior bladder neck shows significantly stronger contraction to alpha-adrenergic agonists compared with cholinergic agonists; the anterior bladder neck does not have a similarly significant differential response. The uniform response to noradrenaline may underlie the bladder neck's role in the prevention of retrograde ejaculation. The differential responses to carbachol may reflect differences in the embryological derivation of the anterior and posterior bladder neck fibres or in their innervation. Some of these differences may have clinical importance through the action of therapeutic agents.

Impact of Prostate Median Lobe Anatomy on Robotic-assisted Laparoscopic Prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) is becoming widely used for the management of prostate cancer. Although prostate size does not affect operative times for RALP, the effect of a large median prostate lobe has not been described. One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. Patients were categorized into 2 groups based on the presence or absence of a large median prostate lobe identified during RALP. The RALP was divided into sections from bladder mobilization to vesicourethral anastomosis. Operative times and outcomes were recorded prospectively. Of the 154 patients, 29 (18%) of the men had large median prostate lobes. Men with large median lobes were slightly older, but had similar prostate-specific antigen, body mass index, clinical and pathologic stage, biopsy and prostatectomy Gleason grade, tumor volumes, and surgical margin rate compared with men without median lobes. Yet, prostate weight, estimated blood loss, and hospital stay was significantly greater in men with large median lobes. The overall operative time for the RALP was greater in men with a large median lobe caused by an increased time required for posterior bladder neck and seminal vesicle dissection. There was no difference in complications such as urine leaks, bladder neck contractures, and migration of Hem-o-lok clips into the bladder. Continence at 3 and 6 months after RALP were not significantly different in men with large median lobes. Despite equivalent oncological outcomes, we demonstrate a significant increase in operative times among men with large median lobes.

Laparoscopic Repair of Vesico-Vaginal Fistula without Bladder Bipartition

To demonstrate a laparoscopic vesico-vaginal fistula repair without bladder bipartition associated with omentoplasty. Material and Method: A 36-year-old woman had a vesico-vaginal fistula caused by the ressection of a vaginal vault endometriotic nodule 1 year after hysterectomy. Complete dissection of the fistula tract borders was performed and vaginal and vesical orifices were closed by interrupted 3–0 Vicryl sutures with interposition of a pediculated omental flap. Results: Total operation time was 130 minutes. The patient had minimal post operative pain and blood loss. There were no complications nor fistula recurrence. Conclusion: Laparoscopy is a good option for fistula repair, allowing the surgeon to perform a reliable posterior bladder suture without bipartition.

Modified posterior reconstruction of the rhabdosphincter: application to robotic‐assisted laparoscopic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) is being performed more frequently as a treatment for presumed localized prostate cancer. With the stage migration that has occurred in prostate cancer diagnosis, urologists are now frequently treating younger men with organ-confined disease, who have good preoperative urinary and sexual function [1]. As the recovery period shortens, issues such as urinary incontinence play a larger role in the patient’s perception of recovery. Surgeons are making technical modifications to their surgical approach to improve ‘early continence’ after prostatectomy.In 2001, Rocco F. et al. [2] described a technique for posterior reconstruction of the rhabdosphincter. This entailed a two-layered reconstruction with apposition of the free edge of Denovilliers’ fascia and the posterior bladder with the posterior aspect of the

Robotic-assisted laparoscopic bladder diverticulectomy and concomitant ureteral re-implantation: initial clinical experience.

We present our initial clinical experience with robotic-assisted laparoscopic bladder diverticulectomy with associated ureteral re-implantation. A 75-year-old man was referred to us for recurrent urinary tract infections and lower urinary tract symptoms. On computed tomography of abdomen and pelvis the patient was found to have a 13×14×6cm diverticulum in the left posterior bladder wall. The patient elected to undergo robotic-assisted laparoscopic removal of the diverticulum. The patient's preparation, draping, and trocar placement was performed as per standard fashion of robotic-assisted laparoscopic radical prostatectomy. The bladder was mobilized and diverticulum was identified and removed. The left ureter was transected secondary to its passage through the diverticulum, and required re-implantation. After hemostasis was achieved, the repair was tested and confirmed. The operation was completed in 207min without any complications. Estimated blood loss was 150cc. On postoperative day 1, the patient was placed on oral analgesic and discharged home. Our initial report of robotic-assisted laparoscopic bladder diverticulectomy and ureteral re-implantation illustrates that this minimally invasive technique is an effective method of treatment of bladder diverticulum. Proximity of the ureter to the diverticulum should not be a deterrent for this approach of repair.

Robotic-assisted Laparoscopic Approach for Posterior Bladder Neck Dissection and Placement of Pediatric Bladder Neck Sling: Initial Experience

Bladder neck sling cystourethropexy is a common procedure used to correct intrinsic sphincter deficiency in children with spinal dyspharism. Various modifications of the procedure have been made but all involve circumferential dissection of the bladder neck and proximal urethra. The posterior dissection can be challenging and can result in injury to the rectum, urethra, or vagina. The posterior approach to the bladder neck as reported by Lottmann and later by de Badiola addresses these potential complications. Using these principles of the posterior approach, we performed a robotic-assisted laparoscopic placement of an acellular human dermal allograft bladder neck sling in 2 patients. We present our initial experience regarding this surgical technique. The diagnosis of intrinsic sphincter deficiency was established in 2 female patients, aged 9 and 10 years. Both patients had a neurogenic bladder secondary to spina bifida. Video urodynamics confirmed adequate bladder compliance and intrinsic sphincter deficiency. Robotic-assisted laparoscopic placement of a bladder neck sling was performed in both patients. Both procedures were completed intracorporeally. The mean blood loss was 20 mL. The mean operative time was 189 minutes. No intraoperative or postoperative complications occurred. The mean hospital stay was 3 days (range 2-4). The follow-up ranged from 13 to 22 months. Postoperative studies revealed continued low-pressure, compliant bladders and stable upper tracts. At last follow-up, the 2 patients were using catheterization without difficulty and were continent. The robotic-assisted laparoscopic approach to performing bladder neck dissection and placement of a bladder neck sling in children is technically feasible.

Post-traumatic female urethral reconstruction

Post-traumatic urethral damage resulting in urethrovaginal fistulas or strictures, though rare, should be suspected in patients who have unexpected urinary incontinence or lower urinary tract symptoms after pelvic surgery, pelvic fracture, a long-term indwelling urethral catheter, or pelvic radiation. Careful physical examination and cystourethroscopy are critical to diagnose and assess the extent of the fistula. A concomitant vesicovaginal or ureterovaginal fistula should also be ruled out. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits volitional, painless, and unobstructed passage of urine. An autologous pubovaginal sling, with or without a Martius flap at time of reconstruction, should be considered. The three approaches to urethral reconstruction are anterior bladder flaps, posterior bladder flaps, and vaginal wall flaps. We believe vaginal flaps are usually the best option. Options for vaginal repair of fistula include primary closure, peninsula flaps, bilateral labial pedicle flaps, and labial island flaps. Outcomes are optimized by using exacting surgical principles during repair and careful postoperative management by an experienced reconstructive surgeon.

Complications of Primary Closure of Classic Bladder Exstrophy

We report the urological, orthopedic and neurological complications of primary closure of classic bladder exstrophy using modern staged repair of exstrophy. An approved database identified 137 males and 57 females with classic bladder exstrophy who underwent primary repair by 1 of 2 surgeons in 23 years. A total of 185 patients underwent primary closure using modern staged repair of exstrophy with or without osteotomies, whereas 9 underwent delayed primary closure with epispadias repair at age 12 months. Of the patients 63 received osteotomies. Mean age at closure was 60 days and mean followup was 9 years. There were 14 major complications (11%) and 27 minor complications (14%). Major urological complications included bladder prolapse or dehiscence in 6 male patients (3%), which was successfully reclosed. Major orthopedic complications, including osteotomy nonunion in 2 cases, leg length inequality in 1 and persistent joint pain in 1, developed in 4 of the 63 patients (6%) who underwent osteotomy. Major neurological complications included femoral nerve palsy in 4 patients (2%). There were 21 minor urological complications (11%), including posterior bladder outlet obstruction in 4 cases, urethrocutaneous fistula in 2, suprapubic tube removal in 2, intrapubic stitch erosion in 4, febrile urinary tract infection in 6 and surgical site infection in 3. Six patients (3%) had minor orthopedic complications, including pelvic osteomyelitis in 1, pin site infection in 3 and a pressure sore from immobilization in 1. Closure of bladder exstrophy is a safe surgery with an acceptable risk of complications. A critical review of outcomes provides insight to further refine the technique and manage complications when they develop.

Assisted Laparoscopic Artificial Urinary Sphincter Implantation in the Pediatric Population

PURPOSE We present our experience in the posterior bladder approach using laparoscopic techniques to place an Artificial Urinary Sphincter (AUS). MATERIAL AND METHODS : From 1990 to 2006. 132 pediatric patients with urinary incontinence underwent artificial urinary sphincter placement. In the last 4 years we used the posterior laparoscopic bladder approach in 8 patients to dissect the bladder neck under direct vision. There were 6 female and 2 male patients with a mean age of 8,7 years (range:3-20) and mean weight of 29,5 kg (range:14-72). The etiology of incontinence in all the patients was myelodysplasia. 3 patients had simultaneous surgical procedures. In 2 cases a laparoscopic Malone procedure was done and in the third we performed a subureteral endoscopic injection of bulking agent. After a complete laparoscopic exposure of the posterior and lateral walls of the bladder neck, a Phannestiel incision was made to place the components of the AUS-800. RESULTS The mean follow up was 23 months (range:3-38). The average surgical time was 188 minutes (range 145-220), mean oral feeding begun at 17,4 hs postop. (range 3-24) and hospital stays from operation until discharge were 1,4 days (range 1-2). We had no intraoperative complications. One patient presented with a bilateral uretero vesical obstruction after the cuff activation that required an extravesical reimplantation. CONCLUSIONS The laparoscopic dissection of the bladder neck is safe and secure. It is not technical demanding and it gives the possibility to dissect the posterior wall of the bladder neck under direct vision. The RESULTS in achieving continence are similar to those reported in the literature.

Assisted Laparoscopic Artificial Urinary Sphincter Implantation in Pediatric Population

PURPOSE We present our experience in posterior bladder approach using laparoscopic techniques to place an Artificial Urinary Sphincter (AUS). MATERIAL AND METHODS From 1990 to 2006. 132 pediatric patients with urinary incontinence underwent artificial urinary sphincter placement. In the last 4 years we used the posterior laparoscopic bladder approach in 8 patients to dissect the bladder neck under direct vision. There were 6 female and 2 male patients with a mean age of 8,7 years (range:3-20) and mean weight of 29,5 kg (range:14-72). The etiology of incontinence in all the patients was myelodysplasia. 3 patients had simultaneous surgical procedures. In 2 cases a laparoscopic Malone procedure was done and in the third we performed a subureteral endoscopic injection of bulking agent. After a complete laparoscopic exposure of the posterior and lateral walls of the bladder neck, a Phannestiel incision was made to place the components of the AUS-800. RESULTS The mean follow up was 23 months (range:3-38). The average surgical time was 188 minutes (range 145-220), the mean oral feedin begun at 17,4 hs postop. (range 3-24) and hospital stays from operation until discharge were 1,4 days (range 1-2). We have no intraoperative complications. One patient presented a bilateral uretero vesical obstruction after the cuff activation that required an extravesical reimplantation. CONCLUSIONS The laparoscopic dissection of the bladder neck is safe and secure. It is not technical demandant and it gives the possibility to dissect the posterior wall of the bladder neck under direct vision. The results in achieving continence are similar to the reported in the literature.

RECONSTRUCTION OF COMPLEX POSTERIOR URETHRAL AND BLADDER NECK STENOSIS AFTER PROSTATE CANCER TREATMENT

You have accessJournal of Urology1 Apr 2008RECONSTRUCTION OF COMPLEX POSTERIOR URETHRAL AND BLADDER NECK STENOSIS AFTER PROSTATE CANCER TREATMENT Bryan B Voelzke, Sean P Elliott, and Jack W McAninch Bryan B VoelzkeBryan B Voelzke More articles by this author , Sean P ElliottSean P Elliott More articles by this author , and Jack W McAninchJack W McAninch More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)60749-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "RECONSTRUCTION OF COMPLEX POSTERIOR URETHRAL AND BLADDER NECK STENOSIS AFTER PROSTATE CANCER TREATMENT." The Journal of Urology, 179(4S), p. 259 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 259 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Bryan B Voelzke More articles by this author Sean P Elliott More articles by this author Jack W McAninch More articles by this author Expand All Advertisement PDF downloadLoading ...

Implanted Mouse Bone Marrow-Derived Cells Reconstruct Layered Smooth Muscle Structures in Injured Urinary Bladders

This study is a preliminary investigation to determine if bone marrow-derived cells, when implanted into freeze-injured urinary bladders, differentiate into smooth muscle cells and reconstruct smooth muscle layers. Bone marrow cells were harvested from femurs of male ICR mice and cultured in collagen-coated dishes for 7 days. After 5 days of culture, the cells were transfected with green fluorescent protein (GFP) genes for identification in recipient tissues. Three days prior to implantation, the posterior urinary bladder walls of female nude mice were injured with an iron bar refrigerated by dry ice. Seven days after the culture and 3 days after the injury, adherent, proliferating GFP-labeled bone marrow-derived cells (1.0 x 10(5) cells) were implanted into the injured regions. For controls, a cell-free solution was injected. At 14 days after implantation, the experimental urinary bladders were analyzed by histological, gene expression, and cystometric investigations. Just prior to implantation, the injured regions did not have any smooth muscle layers. After 14 days, the implanted cells surviving in the recipient tissues were detected with GFP antibody. The implanted regions had distinct smooth muscle layers composed of regenerated smooth muscle marker-positive cells. The implanted GFP-labeled cells differentiated into smooth muscle cells that formed into layers. The differentiated cells contacted each other within the implanted region as well as smooth muscle cells of the host. As a result, the reconstructed smooth muscle layers were integrated into the host tissues. Control mice injected with cell-free solution developed only few smooth muscle cells and no layers. Cystometric investigations showed that mice with implanted the cells developed bladder contractions similar to normal mice, whereas control mice did not. In summary, mouse bone marrow-derived cells can reconstruct layered smooth muscle structures in injured bladders to remediate urinary dysfunction.

Vesico-appendiceal fistula in a mucinous adenocarcinoma of the appendix

BACKGOUND: A rare case of vesicoappendiceal fistula secondary to mucinous adenocarcinoma of the appendix is presented. CASE REPORT: A 62-year-old man with a one year history of recurrent urinary tract infections. After two months he developed pneumaturia and fecaluria. An abdominal and pelvic computed tomography demonstrated a trans-mural mass in the posterior wall of the bladder with a vesicoenteric fistula leading to the terminal ileum. Laparotomy revealed a tumor arising from the appendix contiguous with the bladder posterior wall. The bladder was opened and a large fistula and tumor on the posterior bladder wall near the trigone was identified. Frozen pathological analysis showed a mucinous adenocarcinoma. En-bloc right hemicolectomy and partial cystectomy, preserving bladder trigone was performed. After manipulating the tumor, grossly leakage of mucinous materials occurred into the pelvic cavity. A peritoneal washing with a mytomicin solution at 42º C was then performed, to prevent peritoneal seeding. The patient had a prolonged postoperative ileus and was discharged at the 15th day. Five months after the procedure the patient was recieving chemotherapy with 5-fluoracil and leucovorin and there was no signs of recurrent disease. CONCLUSION: The presentation with vesico-appendiceal fistula is extremely rare with only a few cases reported in the literature. Knowledge of different types of neoplasm and appropriate treatment allows the surgeon to provide patients optimal care referring to specialized centers whenever appropriate.

Submucosal endocervicosis of the bladder: An ectopic, glandular structure of Müllerian origin

Endocervicosis of the bladder is a rare, benign variant of endometriosis. The lesions are characterized by ectopic, glandular structures of Müllerian origin with intracytoplasmic mucin production. During placement of a ureteral stent, a cystic tumor in the posterior bladder wall was discovered in a 47-year-old woman with nephroureterolithiasis. CT and MRI revealed a 5 x 1.6 cm(2) mass in the posterior bladder wall protruding into the lumen of the bladder. Urine culture and cytological analyses showed no malignancy. Transurethral biopsy of the tumor confirmed the diagnosis of endocervicosis. Complete transurethral resection was rejected due to the absence of symptoms and the benign condition of the lesion.

A case of bladder endometriosis successfully treated by laparoscopic resection

We managed a rare case of bladder endometriosis in a 42-year-old woman that was successfully treated by laparoscopic surgery.Approximately 2 years previously she sought evaluation in the Urology Department at another hospital with painful urination during menstruation. Cystoscopy revealed a sessile polypoid lesion on the posterior bladder wall, and thus a transurethral biopsy of the mass was performed. The pathologic evaluation confirmed endometriosis of the bladder. She was referred to our hospital for treatment of bladder endometriosis. Partial resection of the bladder was performed by laparoscopic surgery. She was symptom-free 8 months after resection of the bladder endometriosis.Partial resection of the bladder containing all of the bladder endometrial implants during laparoscopic surgery is considered to be an effective method of management for this condition.