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Objective To review the incidence of defunctionalized bladder–related complications in patients who have had a supravesical urinary diversion for intractable urinary incontinence without concomitant cystectomy. Materials and Methods We retrospectively analyzed the records of patients requiring urinary diversion for intractable urinary incontinence from 1996 to 2011 at our institution. Patients were excluded from the cohort if they had evidence of bladder outlet obstruction or a cystectomy at time of diversion, or had been diverted for active malignancy. Sixty patients underwent a supravesical urinary diversion without concomitant cystectomy for intractable urinary incontinence. The etiology of the urinary incontinence was overtly neurogenic in 28 patients and non-neurogenic in 32 patients. Patients had an average follow-up of 45 months (range, 9-96). The indications for surgery, previous surgical interventions, complications of surgery, and long-term outcomes, including the incidence of pyocystis and the need for secondary cystectomy in the postoperative period were reviewed. Results Four of 60 patients (7%) experienced complications relating to the defunctionalized bladder; this included pelvic pain and pyocystis. Only 1 patient required admission to hospital for treatment of pyocystis, the remaining 3 patients were successfully managed as outpatients with oral antibiotics or analgesics. No patient required a secondary surgical procedure for the defunctionalized bladder. Conclusion Pyocystis and the need for a secondary cystectomy were rare complications in this cohort; we therefore believe that a concomitant cystectomy is unnecessary in patients undergoing supravesical urinary diversion for intractable urinary incontinence.

Objectives To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets. Methods A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications. Results With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively. Conclusions High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Objectives Recurrent incontinence after implantation of an artificial urinary sphincter (AUS) may be due to urethral atrophy. Treatment options consist of decreasing the cuff size, increasing the balloon pressure, implanting a double-cuff system, or proximal cuff repositioning. The first three options may increase the risk of erosion. Increasing the balloon pressure does not effectively increase cuff pressure. This article demonstrates that proximal cuff repositioning is a safe, simple, and effective technique in the management of recurrent incontinence as a result of a loss of cuff compression due to urethral atrophy. Methods Six patients underwent proximal repositioning of the AUS (AS-800) cuff for recurrent post-prostatectomy incontinence. Urethral atrophy was determined by a thorough systematic evaluation. A detailed description of the surgical technique is provided. Results Five of 6 patients (83%) had significant improvement in incontinence with an average follow-up of greater than 1 year. In 1 patient with no improvement, preoperative urodynamics revealed poor detrusor compliance in addition to sphincter weakness due to loss of cuff compression. Conclusions Proximal cuff repositioning on the bulbar urethra is an effective, safe, and simple technique in the management of recurrent incontinence due to urethral atrophy and may minimize the risk of erosion.

The urologic management of the spina bifida child has evolved considerably over the past 10 years. Clinicians now more fully understand the nature of the bladder dysfunction and are therefore able to modify this behavior by either conservative or surgical measures. The spina bifida child and parents can now be confident that the bladder can be appropriately rehabilitated with significant improvement in quality of life.

Objective . To determine the efficacy of the vaginal wall sling in the management of recurrent stress urinary incontinence (SUI) in an elderly female population. Method . Eighteen elderly female patients (average age 68.4 years) with recurrent stress urinary incontinence were studied with a thorough evaluation including videourodynamics. Thirteen patients were diagnosed with type III SUI and 5 patients had type II SUI. A description of the technique, first described by Raz, is provided. Results . Follow-up ranged from six to forty-two months (average 18 months.) All patients are completely dry and express satisfaction with their outcome. Seventeen of 18 patients (94%) are voiding spontaneously. One patient at twelve months' postoperation requires clean intermittent catheterization. Conclusion . Many elderly female patients with recurrent stress urinary incontinence have intrinsic urethral sphincteric incompetence as well as recurrent hypermobility that often classifies them as type II SUI. The vaginal wall sling addresses both problems and is a safe, simple, and effective procedure in the management of recurrent incontinence in elderly female patients.

This is a case report of a fatal spontaneous perforation of an augmentation enterocystoplasty in a twenty-nine-year-old T12 paraplegic, thirteen months post augmentation and placement of artificial urinary sphincter. A review of the literature involving 41 episodes in 31 patients is provided with a discussion concerning presentation, etiology, and management.

SUMMARY The treatment of voiding complaints and incontinence in painful bladder syndrome requires careful attention to detail. As the exact nature of these conditions is unknown, no single modality is effective, and multiple treatments may be required. A sympathetic and supportive physician is necessary in all these cases.

In developed nations, vesicovaginal fistulas are most commonly encountered as a complication after gynecologic surgery. Most fistulas are corrected using a transvaginal approach; however, complicated cases often require intraabdominal repair. A novel abdominal approach is described, using a small anterior cystotomy and omental pedicle interposition.

When synthetic materials are used for the construction of pubovaginal slings, urethral erosions may occur. This complication has not been reported with fascial slings. We present a case of a 34-year-old woman who underwent a pubovaginal sling procedure using rectus fascia. After 10 weeks of urinary retention, urethroscopy identified an erosion of the sling at the midurethra. Surgical revision restored normal voiding without recurrent stress incontinence. Although urethral erosions have been reported with synthetic suburethral slings, this case suggests that erosions can also occur with fascial slings. Careful positioning and minimal tension on the sling arms may minimize this risk.

The technetium methylene diphosphate bone scan was elevated in 100 consecutive new patients presenting with carcinoma of the prostate. 48% of the patients has a positive bone scan at the initial diagnosis. The scan was more helpful than the skeletal X-ray in the diagnosis of bone metastases: 23% of the X-ray-negative patients were scan-positive. Serial bone scans were more sensitive than either X-rays or serum acid phosphatase in following the progress of the disease. It is concluded that the bone scan in patients with prostatic carcinoma can be used as a reliable tumour marker, especially for monitoring the course of metastases.

OUR PREVIOUS studies have suggested that certain effects of psychotherapy and placebos on psychiatric outpatients may depend on the potentiation and activation of the patient’s favorable expectations.(Q) GOLDSTEIN(~) has pointed out the important role played by the patient’s expectations that he will improve, that he will receive a certain type of treatment, and that. he and the thergpist will behave in ctrtain ways. This paper reports a controlled study of the effects on psychiatric outpatients of a pre-treatment interview designed to clarify their expectations of psychotherapy and to increase the congruence of their behavior with therapists’ expectations as to how psychiatric patients should act. We tested the hypotheses that such an interview would favorably affect patient’s behavior during therapy and the outcome after four months of treatment. Because of the diversity and ambiguities of public conceptions of mental illness and psychotherapy, psychiatric patients reach the psychiatrist’s office with a wide variety of attitudes and expectations. Only the most sophisticated are perfectly clear about why they are there and what they expect (Ref. 4. p. 128). Less sophisticated patients may have unrealistic expectations for improvement: they may not understand their role in the therapeutic process@) and may be bewildered by a procedure that differs not only from usual medical treatment but from customary social interactions. As LENNARD and BERNSTEIN comment (Ref. 6, p. 26) : “Dissymetry of expectations not only interferes with the therapeutic task, but can actually lead to the premature death of a therapeutic system.” This might be an important reason why patients who are less educated and have a different cultural background than most therapists tend to terminate treatment prematurely.(‘W)