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PURPOSE: We determined the oncologic and urological outcomes in patients with bladder/prostate rhabdomyosarcoma according to the type and timing of urinary tract surgery, with emphasis on the role of the Padua orthotopic ileal neobladder. MATERIALS AND METHODS: We retrospectively analyzed oncologic and urological outcomes of 11 consecutive patients treated at our institution between 1998 and 2012. RESULTS: Two patients underwent urethrectomy and placement of a heterotopic catheterizable ileal neobladder. The membranous urethra was preserved in 9 patients, 6 underwent primary Padua ileal neobladder at radical cystectomy, 2 underwent delayed Padua ileal neobladder and 1 underwent bilateral cutaneous ureterostomy. Four of these 9 patients experienced disease recurrence, including local recurrence in 2 despite negative intraoperative biopsies. Survivors undergoing heterotopic catheterizable ileal neobladder or primary Padua ileal neobladder learned to empty the bladder to completion without long-term upper tract deterioration. Both cases managed by delayed Padua ileal neobladder required clean intermittent catheterization eventually. Erections were reported in 5 of 6 surviving males. CONCLUSIONS: The Padua ileal neobladder allowed preservation of volitional urethral voiding in all survivors in whom it was placed at radical cystectomy. Nevertheless, local recurrence was noted in 2 of the 9 cases where the membranous urethra was preserved. By comparison, patients undergoing delayed Padua ileal neobladder after attaining disease-free status never achieved voiding per urethra. Therefore, a heterotopic reservoir might be a more reliable choice under these circumstances. Erectile function is preserved in the majority of cases.

The purpose of our study was to examine postoperative changes and recovery in voiding efficiency after intravesical and extravesical ureteral reimplantation. Retrospective review was performed of 188 cases. Inclusion criteria were the presence of primary vesicoureteral reflux and the absence of previous lower urinary tract surgery. Voiding efficiency after ureteral reimplantation was assessed based on post-void residual volume measurements. It was found that postoperative voiding efficiency of patients in the extravesical unilateral group was similar to that in the intravesical group, while the extravesical bilateral group had a statistically significantly higher proportion of patients with transient voiding inefficiency. A statistically higher proportion of those in the extravesical bilateral group also required some form of urinary catheter drainage for a longer period. However, on more prolonged followup all evaluable patients in the 3 groups fully regained voiding efficiency.

Udgivelsesdato: 2009-Oct PURPOSE: We studied the effect of transcutaneous electrical nerve stimulation in children with overactive bladder and treatment refractory daytime urinary incontinence. MATERIALS AND METHODS: We recruited 27 children 5 to 14 years old with daytime urge incontinence refractory to timer assisted standard urotherapy and anticholinergics who had normal urinalysis, and unremarkable urinary tract ultrasound and physical examination. Study exclusion criteria were bladder underactivity, lower urinary tract obstruction, ongoing defecation disorders, lower urinary tract surgery and previous transcutaneous electrical nerve stimulation. After a 2-week run-in of standard urotherapy the children underwent natural fill ambulatory urodynamics to confirm detrusor overactivity. Subsequently they were randomly allocated to 4 weeks of 2 hours of daily active or placebo S2-S3 transcutaneous electrical nerve stimulation. The severity of incontinence and urgency, and 48-hour bladder diaries were recorded before randomization and during intervention week 4. Children withdrew from anticholinergics throughout the study period. RESULTS: Two children were excluded from randomization due to urodynamic signs of lower urinary tract obstruction. After 4 weeks of intervention 8 children (61%) in the active group showed a significant decrease in incontinence severity but this occurred in only 2 (17%) in the sham treated group (p

Laparoscopic urinary tract surgery is rarely performed in small infants. We compared the safety, feasibility and outcome of laparoscopic urinary tract surgery in children weighing 6 kg or less with a weight matched cohort undergoing open urinary tract surgery.We performed a retrospective nonrandomized chart review comparing 17 infants weighing 6 kg or less who underwent laparoscopic urinary tract surgery beginning in 2005 with a weight matched historical group of 18 patients who had undergone open urinary tract surgery. We recorded procedures performed, operative times, blood loss, length of hospitalization, preoperative and postoperative hemoglobin and serum creatinine levels, analgesia requirements, complications and outcomes. Urine output during anesthesia was recorded and expressed as ml/kg per hour. We also recorded intraoperative changes in heart rate, mean arterial blood pressure, peak inspiratory pressure, respiratory rate, oxygen saturation, CO(2) and core body temperature.Estimated blood loss was minimal in all cases. Mean operative time +/- SD was 201 +/- 72 minutes in the laparoscopic group and 112 +/- 36 minutes in the open group (p0.01). Patients undergoing laparoscopic surgery had lower intraoperative urine output but no changes in preoperative or postoperative serum creatinine levels. Mean postoperative hospitalization +/- SD was 2 +/- 1 days in the laparoscopic group and 3.2 +/- 2.18 days in the open group. Mean opioid requirement (morphine equivalent) +/- SD was higher in the open group, at 0.24 +/- 0.15 mg/kg, compared to the laparoscopic group, at 0.13 +/- 0.19 mg/kg. Operation related complications were diagnosed in 1 patient (6%) from the laparoscopic group and 2 patients (11%) from the open group.Laparoscopic urinary tract surgery can be performed safely in neonates and small infants with outcomes comparable to that of open surgery, with decreased analgesia requirements and faster recovery.

A tension-free bowel anastomosis is essential when bowel segments are used in reconstructive urological procedures. A safe and effective technique is described to lengthen the mesenteric vascular pedicle. Serial incisions are made in the mesenteric peritoneum horizontally, perpendicular to the vascular plane on both sides of the mesentery. This technique has provided up to 3 cm. of additional length without complication in 3 cases.

Argon beam coagulation is a new form of electrocautery that has proved useful to control diffuse bleeding in other surgical specialties. We report its application to urology. Three cases are presented in which argon beam coagulation provided excellent hemostasis in situations that are often difficult to control, such as partial nephrectomy for penetrating trauma, hemorrhagic cystitis refractory to other forms of treatment and after anterior exenteration for bladder cancer. The basis, technique and advantages of argon beam coagulation are discussed, as well as other instances in urological surgery in which it may have application. Argon beam coagulation is an alternative to conventional methods of hemostasis whenever there is a diffusely bleeding operative site.

Surgery on lower urinary tract organs sometimes is hindered by the symphysis pubis, which by its position and bulk could severely restrict maneuverability. Since 1972 we used a transpubic approach to improve surgical exposure in 287 patients operated on for prostate, bladder or urethral cancer, post-traumatic strictures and other conditions. The type of pubectomy performed (total, partial superior or partial inferior) depended upon whether a suprapelvic or infrapelvic diaphragm organ was the primary target of the approach. Total pubectomy was used in 137 patients, partial superior bone resection in 140 and partial inferior resection in 10 patients. Technical details for each type of pubectomy are illustrated. The transpubic approach was particularly useful for repair of posterior urethral strictures or removal of bulky tumors. Among the 3 types of approaches used, total pubectomy was associated with a high complication rate including bleeding, pelvic instability, urinary incontinence and stricture of the vesicourethral anastomosis. Therefore, we have abandoned the technique since 1978. Partial pubectomy provides exposure comparable to that of total pubectomy but with minimal complications, making it an alternative to the standard approach in difficult cases.

Indwelling ureteral stents are a useful addition to the urologic armamentarium. The current double-J ureteral stent offers the advantages of ease of endoscopic insertion, exceptional patient tolerance and improved resistance to incrustation. We used these stents in 87 patients: to bypass obstruction in 57, as an adjunct to complicated upper tract surgery in 15, as initial treatment of upper urinary fistulas in 10 and for miscellaneous reasons in 5. The majority of the stents were placed endoscopically (58 per cent) and under local anesthesia (54 per cent). Half of the urinary fistulas healed without an operation and none of the patients treated with stents for malignant obstruction was hospitalized for more than 4 days. The stents were changed easily on an outpatient basis under local anesthesia and patient tolerance was excellent. When used as adjuncts to open procedures the stents frequently allowed for shorter hospital stay, since postoperative urinary drainage was decreased markedly. Of the 136 stents used in our series 13 became obstructed, usually after they were indwelling for more than 8 weeks. Irritative symptoms were noted in only 6 patients and responded well to pharmacologic therapy. We have found the double-J ureteral stent useful and reliable in patients with ureteral obstruction, as adjuncts to genitourinary surgery in selected instances and as internal diversion for upper urinary tract fistulas.

Hydrometrocolpos usually occurs in the neonatal period. The majority of cases are caused by vaginal occlusion by a transverse septum combined with cervical secretion. Although not well appreciated genital distension by urine may occur in some cases with a persistent urogenital sinus or cloaca. We report 3 cases of urinary and 8 cases of secretory hydrometrocolpos. The frequency of associated anomalies, especially in the urogenital tract, was high (9 of 11 patients), which was the most important factor in determining the morbidity and mortality. Of the patients 2 died, and 9 are alive and healthy, demonstrating that the prognosis of hydrometrocolpos is excellent. The diagnosis of hydrometrocolpos should no longer be difficult to determine. The most important step is a thorough vaginal examination, although modern imaging methods may be helpful. The aim of treatment is distal vaginal drainage, which can be achieved by a perineal procedure in most cases. Laparotomy is indicated only in cases of high vaginal atresia, which require a vaginal pull-through procedure.