Results In Terms Of Continence Research Articles

Treatment of female recurrent or not stress urinary incontinence with intrinsic sphincter deficiency: Sub-urethral retropubic adjustable sling (Remeex)

Recommendations for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincteric deficiency (ISD) or recurrent, are complex. They accept the use of sub-urethral slings (BSU), if unsuccessful the artificial urinary sphincter. The objective was to report the results in terms of continence and morbidity of the Remeex® Adjustable BSU in the treatment of SUI by ISD recurrent or non-recurrent. Monocentric retrospective study of 70 patients with a mean age of 67.7 years (±12) operated of Remeex sling, between 2015 and 2019, was conducted. Preoperative and postoperative characteristics were analyzed from medical records. Two groups were analyzed: Group A (n=28) with no history of incontinence surgery and Group B (n=42) with history (recurrent). Patients who were totally continent (0 protection) and those who were socially continent (1 safety protection) were considered successful. Postoperative success rate was similar between groups B (90%) and A (92%) with respectively: 64% versus 71% of totally continent patients, 26% versus 21% wearing safety protection. The postoperative complications were mainly Clavien II (28%) such as urinary tract infections (6%), transient urinary retention (3%) and de novo bladder overactivity (20%) with no significant statistical difference between the groups. Six patients were reoperated (Clavien III): BSU detension (1%), vaginal exposure (4%) (including one total material removal for infection), varitensor explantation (1%) or scar disunion (1%). The Remeex® BSUA seems to lead to satisfactory perioperative results in patients with SUI with ISD recurrent or non-recurrent.

Application of the Monti procedure in Adult Continent Cutaneous Urinary Diversion.

Introduction; Monti and co. described in 1997 is a continent catheterizable conduit using short segments of the ileum (1). The use of this technique allows us to obtain 2 to 2.5 cm segment of the ileum to achieve a tabularized segment of 7-8 cm. The 15 cm of terminal ileum was not routinely used for this type of procedure. After the reconstruction of a tunnel, anastomosis was performed on the superior part of the posterio-lateral junction of the bladder.
 Objectives: To report 6 cases using the Monti procedure with ileum for adult continent cutaneous urinary diversion, from different etiologies.
 Materials and Methods: From 2007 to 2020 we treated 6 patients with different conditions with this procedure. First case was a middle-aged woman with a big vesico-vaginal fistula (fig.3) It was unappropriated to be closed with satisfactory functional results in terms of continence, because a part of the sphincter was destroyed also. The reason of damage was auto mutilation as a result of borderline personality.
 Discussion: Monti procedure associating Mitrofanoff principle was mainly used in pediatric patients (1,2,3) That’s because of the relatively easy execution of the “Mitrofanoff principle” and the high degree of continence obtained with its use (4). But can we use the same principle to resolve some difficult cases in adult urology also?
 Conclusion: The Monti tunnel is a valid option for continent intermittent catheterisation. It’s also an alternative to be adjunct with Mitrofanoff procedure when needed. We used it when the appendix was not appropriate to be used as a tunnel or when it was missing. It has a good continent percentage and it can be done rather easily. Of course, ours is a small series of cases to represent more important conclusions.

Transperineal Intracath Meconiolysis and Evacuation Technique of "Distended" Bowel Evacuation for One-Stage Laparoscopic Anorectoplasty for High Anorectal Malformations in Males.

Introduction: One-stage anorectoplasty provides maximum potential for "normal" defecation reflexes right at birth and avoids complications and problems of colostomy. One-stage laparoscopic anorectoplasty (OSLARP) for rectourinary fistula (RUF) is restricted by distended bowel obscuring the working space for laparoscopy. This study describes transperineal intracath meconiolysis and evacuation (TIME) technique for OSLARP in the treatment of RUF in neonates. Materials and Technique: High male anorectal malformation (ARM) admitted from January 2016 to March 2019 were included in the study. Diagnosis of level of ARM was made on the basis of invertogram. Patient presenting with lethal comorbidities were excluded who underwent colostomy. The technique involved placement of a 16G intracath in the perineum through the site of future neo-anus, which was identified using muscle stimulator. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl. The creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Results: Seventeen patients were selected for TIME technique but on laparoscopy 2 patients had severe necrotizing enterocolitis hence they underwent laparoscopy-assisted high sigmoid colostomy. Fifteen patients underwent OSLARP successfully. Mean weight was 2.5 ± 0.4 kg, mean gestational age was 36 ± 5 weeks, and mean age of presentation was 3.5 ± 1 days after birth. The TIME technique was successful decompressing bowel in all the patients. Out of 15 patients of OSLARP, 14 had rectoprostatic urethral fistula and 1 had rectovesical fistula. Mean total operative duration of OSLARP was 46 ± 15 minutes. Patients who could be followed for 3 years had good results in terms of continence and bowel movements. Discussion: TIME technique is a very simple and effective way to overcome the problem of associated colonic distention in neonatal one-stage laparoscopic anoplasty.

Focal therapy of prostate cancer

The aim of this study was to summarize the latest evidence, as well as the rationale behind using focal therapy for the treatment of prostate cancer. With patients becoming more educated, knowledge of the available evidence is key when discussing treatment. In older works, the natural history of prostate cancer has been described as being multifocal, driven by one index lesion. This represents the key argument for most experts, why focal therapy is feasible in prostate cancer. Most modalities have similar results. For high-intensity focussed ultrasound (HIFU), a pooled data analysis with a median follow-up of 2.2 years showed a negative biopsy rate of 77% with a salvage therapy free rate of 92%. A matched pair analysis comparing irreversible electroporation with robot-assisted radical prostatectomy showed a better side effect profile for focal therapy in evenly matched groups, yet with worse disease-free survival. Interestingly, the better outcomes concerning continence and erectile function did not translate into better patient-reported outcomes. Focal therapy modalities are generally well tolerated and show good results in terms of continence and potency. Long-term follow-up is not available, and inclusion criteria for trials are not yet uniform. Newer technologies, such as photodynamic therapy, are being developed, as well as improvements to older techniques, such as HIFU.

Trocar-guided trans-vaginal mesh surgery for pelvic organ prolapse: effects on urinary continence and anatomical and functional outcomes. A prospective observational study

ObjectivePrimary objective of this study was to assess the effects of trocar-guided transvaginal mesh surgery (TVM) on cure and prevention rates for incontinence, without concomitant surgery for Stress Urinary Incontinence (SUI). Our secondary objectives were anatomical outcomes, relief of symptoms and effect on quality of life (QoL). Study designThis prospective observational study evaluated women who underwent TVM for symptomatic stage >2 Pelvic Organ Prolapse (POP).SUI was evaluated objectively using the cough stress test with prolapse reduced. SUI and urge urinary incontinence (UUI) were subjectively evaluated using ICIQ-SF.Anatomical cure was defined as stage <2 at POP-Q.Statistical analysis: McNemar chi-square test; paired t-test; Mann–Whitney test. ResultsSeventy-two patients reached final evaluation (mean follow-up 72 months).In the 40 pre-op continent patients, 34 (85%) remained continent postoperatively and 6 (15%) showed de novo SUI. Only 1 patient chose to undergo subsequent TVT. The number needed to treat was 6 to prevent 1 women developing de novo objective SUI and 39 to prevent 1 woman having to undergo SUI surgery.In the 32 pre-op incontinent patients, 18 (56.3%) became continent postoperatively. Only 1 patient chose to undergo subsequent TVT.UUI was present in 44 patients pre-operatively and 15 (20.8%) post-operatively (1 de novo).Forty-four patients (61.1%) were continent post-operatively for SUI and UUI.We observed a significant improvement in storage, voiding, post-micturition and prolapse-related symptoms.The anatomical cure rate was 87.5% for the anterior compartment and 90.3%.for the apical segment.The apical recurrence was 8.3% in the patients previously hysterectomised, 18.8% in the patients with uterus preservation and 0% in the patients with concomitant hysterectomy.QoL scores improved in all domains except sleep and personal relationships.We observed mesh exposure in 10 patients (13.9%), in 5 of whom it was associated with a concomitant hysterectomy ConclusionsTVM showed excellent results in terms of continence and can be performed without contemporary anti-incontinence surgery, for both continent and incontinent women. Patients should have pre-operative counselling before POP surgery. For severe uterine prolapse the Perigee™ System should be employed with concomitant hysterectomy because uterus preservation is associated with significantly higher apical recurrence rates.

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

Radical soft tissue mobilization and reconstruction (Kelly procedure) for bladder exstrophy repair in males: initial experience with nine cases

to report the early experience with the Kelly procedure for the treatment of bladder exstrophy (BE) in males. Nine boys with BE were treated at our institute. One had an untouched BE, four had epispadias after neonatal bladder closure, and four were secondary phalloplasties. Data on surgical complications, continence status, presence of erections and parental satisfaction with penile appearance and length are reported. Mean patient age was 4.7 (1-8.9) years. No intra-operative complications occurred. Two secondary cases experienced formation of a bladder-neck fistula and glans ischemia, respectively. The latter led to glans loss. All the patients had some residual degree of hypospadias after surgery. After a median follow-up of 18.1 (10-22) months, one patient developed chronic bladder outlet obstruction. Overall, five patients are dry (including two on clear intermittent catheterization and one with a Minz II pouch). The other four are still younger than 3 years, all have spontaneous micturitions and dry interval between 30 and 120 min. Of the eight patients without phalloplasty complications, all had erections, and parents judged the penile length and appearance as being satisfactory in six cases. The Kelly procedure is feasible in a vast array of BE patients, but may be formidable, especially in secondary phalloplasties. It allows for complete reconfiguration and lightening of the penis, but exposes to potentially catastrophic complications, such as partial or complete penile loss. Longer follow-up is needed to assess the results in terms of continence.

Modified ureterosigmoidostomy for management of malignant and non-malignant conditions

To investigate the outcome of Mainz Pouch II urinary diversion for both malignant and non-malignant diseases. A retrospective analysis. Kilimanjaro Christian Medical Centre, Institute of Urology, Moshi, Tanzania from April 1995 to May 2007. Mainz Pouch II was created in 83 patients of which, 38 were females and 45 were males (M:F 1.2:1). Early complications were seen in 11 (13.2%) patients, as follows: one (1.2%) prolonged ileus, 1(1.2%) wound dehiscence, two (2.4%) perioperative deaths among the malignant group, seven (8.4%) superficial wound sepsis. Long term complications were seen in 14 (16.9%) patients, as follows: one (1.2%) patient developed an incision hernia, one (1.2%) patient developed unilateral pyelonephritis, one (1.2%) patient developed unilateral ureteral stenosis, two (2.4%) patients had deterioration of renal function, three (3.6%) patients developed mild to moderate unilateral hydronephrosis, three (3.6%) patients developed mucoceles. Among the 83 patients in this series, three (3.6%) patients developed metabolic acidosis, two (2.4%) of which, required oral bicarbonate supplementation. All (100%) patients had daytime continence while three (3.6%) patients had occasional night time incontinence. Overall total continence was achieved in 80 (96.4%) of the patients. The Mainz Pouch II is a safe and reproducible method of urinary diversion and serves as a satisfying method of continent urinary diversion in all age groups. This reconstructive surgery enabled the afflicted to achieve personal goals, hopes and aspirations, positively influencing their quality of life. The follow up show low complication rate with good results in terms of continence and quality of life, however, long term results remain to be evaluated.

Intra- and Peri-Operative Outcomes Comparing Radical Retropubic and Laparoscopic Radical Prostatectomy: Results from a Prospective, Randomised, Single-Surgeon Study

ObjectivesTo prospectively compare intra- and peri-operative outcomes of open radical retropubic prostatectomy (RRP) and laparoscopic prostatectomy (LRP) by a single surgeon. Patients and methodsOne-hundred-twenty, consecutive, age-matched patients diagnosed with clinically localized prostate cancer were eligible for surgery. Sixty patients underwent RRP and 60, LRP. Intra- and peri-operative parameters, pathologic findings and early complications were recorded. A validated visual analogue scale was used to assess pain in the recovery room, 3h after the operation and on post-operative days 1, 2 and 3. A cystogram was performed on post-operative day 5. ResultsOperating time was significantly shorter in the RRP group versus the LRP group (mean±SD, 170±34. 2 vs 235±49.9min, p<0.001). Blood loss was significantly less in the LRP group versus the RRP group (mean±SD, 853.3±485 vs 257.3±177ml, p<0.001), but no patient in either group underwent early re-intervention for bleeding. The RRP group showed a trend for higher use of analgesia. A watertight anastomosis was shown at cystourethrography and the catheter removed in 86% and 66% of LRP and RRP patients, respectively. The overall percentage of post-operative complications and positive margins were comparable. ConclusionLaparoscopic prostatectomy is an attractive alternative to open prostatectomy, offering the advantages of reduced blood loss and safe early catheter removal. Furthermore, the laparoscopic procedure proved to be safe oncologically. Long-term follow-up is required to compare functional results in terms of continence and potency.

Modified ureterosigmoidostomy (Mainz Pouch II) in different age groups and with different techniques of ureteric implantation.

To examine the outcome of Mainz Pouch II urinary diversion in different age groups and with different techniques of ureteric implantation. Between March 1995 and August 2002 a Mainz Pouch II was created in 41 patients (27 male and 14 female, median age 56.3 years, range 2-75) with 81 renal units (RU). For analysis, the patients were divided into 29 (70%) aged <65 years and 12 (30%) aged >65 years. Ureteric implantation with the Goodwin-Hohenfellner (GH) technique was used in 55 RU, with the Abol-Enein (AE) modification in 23 and Le-Duc procedure in three. The median (range) follow-up (available for 36 patients, 88%) was 19 (1-80) months. An unvalidated questionnaire was used to determine specific urinary diversion items. Early complications occurred in 7% of patients, none requiring surgical intervention. Pyelonephritis occurred in five of 36 patients and seven of 71 RU (14% of the patients, 10% of the RU); all patients were <65 years old. In five of seven RU pyelonephritis was caused by the development of upper urinary tract dilatation; none required surgical revision. Ureteric stenosis requiring reimplantation occurred in two RU (2%, one GH, one AE). All patients were continent in the daytime; all but one patient had to wake to urinate at night, with 36% having to do so more than six times. Of the patients, 63% were able to distinguish between stool and urine. Initially, alkalinizing drugs to prevent metabolic acidosis were taken by 30% of the patients. Of previously medicated patients with a follow-up of >1 year, 8% required oral alkalinizing medication. The Mainz Pouch II is a safe and reproducible urinary diversion, and serves as a satisfying alternative to other forms of continent urinary diversion in all age groups. The follow-up shows a low complication rate with good results in terms of continence. There were no significant differences in complication rates for the different ureteric implantation techniques. The long-term results remain to be evaluated.

Proctocolectomy and J-pouch ileo-anal anastomosis in children

Background/Purpose: The choice of ileo-anal reconstruction method in children undergoing proctocolectomy remains controversial. Although in adults ileo-anal pouch reconstruction has gained overall acceptance, many paediatric surgeons still advocate straight ileo-anal pull-through. The aim of this study was to assess the outcome and long-term functional results in children who have undergone proctocolectomy and ileo-anal anastomosis (IAA) with a J-pouch. Methods: Medical records of 40 consecutive children who had proctocolectomy and J-pouch IAA between 1991 and 1999 were reviewed for early and late complications, fecal frequency, day- and night-time continence, and pouchitis. The indication for surgery was ulcerative colitis (UC) in 29 (median age at operation, 13 years; range, 9 to 16), Hirschsprung's disease (HD) in 10 (median age at operation, 1.5 years; range, 1 month to 5 years), and familial adenomatous polyposis (FAP) in 1 (age at operation, 6 years). Six of the HD patients had primary pull-through for total colonic aganglionosis and 4 a redo operation for failed primary reconstruction of long segment aganglionosis. Results: There were no fatalities. Early complications (wound infection, early bowel obstruction, prolonged fever) occurred in 12 of 29 (41%) and late complications (bowel obstruction 9, pouch fistula 2) in 11 of 29 (38%) of the UC patients. Overall, 16 of 29 (53%) of the UC patients had complications. All patients with early complications were on systemic steroids at the time of the operation. Pouchitis occurred in 30% of the patients. None of the pouches had to be removed. At last follow-up all patients were continent during the day, 2 patients used protective pads during the night because of occasional staining. The median bowel frequency per 24 hours was 4 (range, 2 to 7); only 2 patients (7%) had to empty their bowel during the night. One (10%) of the HD patients had wound infection, and 3 had episodes of postoperative enterocolitis. Pouchitis-type symptoms have not occurred in HD patients. The median bowel frequency for 24 hours was 3 (range, 2 to 5). None of the HD patients needs to evacuate during the night. The 4 HD patients who are older than 3 years of age are continent. Conclusions: J-pouch IAA is a feasible method of reconstruction in children requiring proctocolectomy. Major complication are common but occur mainly in immunosuppressed patients suffering from UC. Despite high incidence of complications, long-term functional results in terms of continence and bowel frequency are excellent and ensure good quality of life in the great majority of patients. J Pediatr Surg 37:66-70. Copyright © 2002 by W.B. Saunders Company.

Management of bladder exstrophy.

The exstrophy-epispadias complex is a severe anomaly of the lower urinary tract. While the surgical reconstruction of normal anatomy in patients with this disorder was once considered impossible, modern management has made possible a near-normal reconstruction of the bladder and lower abdominal wall. Early operation in the neonatal period along with closure of the pelvic ring has been shown to significantly improve results in terms of continence and achievement of adequate bladder capacity. With the possibility of prenatal diagnosis, it is important that the counseling obstetricians and neonatologists should understand the basis of the surgical management and the outcome that can be expected.

Initial experience with 10 cases of Indiana pouch continent urinary diversion

Indiana pouch continent urinary diversion provides patient control over elimination of urine with periods of dryness. This allows emptying of urine from the pouch by catheter at convenient intervals avoiding major metabolic abnormalities with satisfactory renal function. Detubularization of the ascending colon and caecum with tapering of the terminal ileum and tunneled tenial implants of the ureters have resulted continent cutaneous urinary reservoir. In total 10 patients were included and follow-up period was for a period of 6 months to 5 years. One year after surgery overall day and night continence rate was in 70% patients, some leakage at day and night in 30% cases and no patient developed day or night incontinence. The mean capacity of the pouch was 530 ml at 12-18 months. Pouch pressure at full capacity was 16 cm H2O at 18 months. Indiana pouch provides better attention for urinary diversion in developing countries as it is well accepted, economically more suitable and relatively easy to construct, with good results in terms of continence and reduced complications with satisfactory renal function.