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Surgical excision is the definitive treatment of urethral diverticulum (UD) and the only reasonable surgical option for treating midurethral and proximal UD. Success depends on proper staging by determining the extent and number of diverticula and attention to surgical technique. This article offers practical guidance in adjusting technique to accommodate commonly encountered difficult clinical scenarios., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This article discusses a systematic approach to the repair of cystoceles using interposition grafting. Surgeons' opinions vary regarding which graft is most appropriate as there are several varieties for mesh interposition. High-grade cystocele repair using the porcine dermis interposition graft is successful and associated with few complications. Cystocele repair is typically low grade and does not require additional surgery., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To explore, by histological examination, whether the uterosacral ligament complex is an adequate support structure for vaginal vault suspension and other reconstructive procedures of the female pelvis., Materials and Methods: We dissected 14 fresh hemipelves from seven adult female cadavers. The uterosacral complexes were excised from the pelvic sidewall immediately beneath the uterosacral pedicle. The specimens were stained with connective tissue-specific Movat stain and evaluated microscopically for the presence of collagen and/or elastin., Results: Uterosacral tissue similar to that identified during pelvic reconstructive surgery was obtained in all cases. Six of the women had had a hysterectomy. A ligamentous structure with clearly aligned collagen and interspersed elastin was identified in only three specimens, two from one cadaver of a young woman who had not had a hysterectomy. The other specimens had an attenuated, poorly organized layer of collagen immediately beneath the peritoneum., Conclusion: We could not consistently identify normal ligamentous tissue in the uterosacral complexes. The overwhelming majority of specimens from women who had had a hysterectomy showed disorganized tissue with reduced cellularity. This reinforces doubts about the integrity of these tissues as structural supports in pelvic reconstructive surgery, particularly in elderly women who have had a hysterectomy.

Purpose: The InterStim neuromodulator device (Medtronic, Inc., Minneapolis, Minnesota) is indicated for the treatment of refractory urge incontinence, urinary frequency and urgency, and nonobstructive urinary retention. We present a modification of the 2-stage approach which is simple to perform, reduces the number of incisions from 2 to 1, decreases operative time and potentially decreases the risk of infection., Materials and Methods: Using a single paramedian incision, a quadripolar lead is placed into the appropriate sacral foramen. The lead is connected to the extension wire and the connector is anchored into an ipsilateral subcutaneous tunnel with the aid of an externalized polypropylene suture and plastic button. The extension wire is then externalized through the contralateral buttock using a subcutaneous tunneling device. At stage 2 the entire system can be removed through the original incision or the pulse generator can be implanted through a virgin incision over the connector site., Results: A total of 20 procedures have been performed with an average stage 1 implant time of 72 minutes. Median implant time of 13 pulse generators was 36 minutes. Median explant time of 6 leads was 21 minutes. There have been no infections or adverse events., Conclusions: This modification is simple, efficient, safe and involves use of tools already familiar to urologists. By reducing the number of incisions, it reduces violation of the skin barrier and consequently risk of infection. Infection is potentially reduced at stage 2 because there is undisturbed, noncontused virgin tissue at the site of generator implant.

Purpose: We performed a central review of pathology specimens from radical perineal and radical retropubic prostatectomies performed by a single surgeon. We determined whether differences exist in the 2 approaches in regard to the ability to obtain adequate surgical margins around the tumor and adequate extracapsular tissue around the prostate, and avoid inadvertent capsular incision., Materials and Methods: The review included whole mount prostates from 60 patients who underwent radical retropubic prostatectomy and 40 who underwent radical perineal prostatectomy. The pathologist (N. S. G.) was blinded to the surgical approach. All prostatectomies were consecutive and performed by the same surgeon (H. J. K.). To ensure consistency of the pathological measurements patients were excluded from analysis if they had undergone preoperative androgen ablation or a nerve sparing procedure, leaving 45 retropubic and 27 perineal prostatectomy specimens for further evaluation. Pertinent clinical parameters were assessed and a detailed pathological analysis of each specimen was performed., Results: In the retropubic and perineal groups 78% of the tumors were organ confined (stage pT2) with extracapsular extension (stage pT3) in the majority of the remaining patients. There was no significant difference in the positive margin rate for the retropubic and perineal procedures (16% and 22%, p = 0.53) or for Gleason 6 and 7 tumors only in the 2 groups (10% and 17%, respectively, p = 0.47). The capsular incision rate was 4% in each group. The distance of the tumor from the posterolateral margins and the amount of extracapsular tissue excised were equivalent in each group. Subgroups of patients with a prostate of less than 50 gm. and containing only low grade, low stage neoplasms were also analyzed. Subgroup analysis showed no difference in any variable., Conclusions: Radical perineal prostatectomy is comparable to radical retropubic prostatectomy for obtaining adequate surgical margins, avoiding inadvertent capsular incisions and excising adequate extracapsular tissue around tumor foci. Additional patient accrual and prostate specific antigen followup would further help validate the similar efficacy of the 2 surgical approaches as treatment for prostate cancer.