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The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Total mesorectal excision (TME) has decreased the local recurrence rate and improved the overall survival of rectal cancer patients. However, urinary dysfunction remains a clinical problem after rectal cancer surgery. The aim was to assess the risk factors for postoperative urinary dysfunction., Methods: This study was a single-center, retrospective analysis of 104 patients who underwent laparoscopic rectal surgery between November 2016 and October 2017. Postoperative urinary dysfunction was defined as the need for urinary catheter re-insertion or the presence of residual urine (≥ 150 mL) postoperatively., Results: Postoperative urinary dysfunction was seen in 18 patients (17%). Multivariate analysis showed that male sex (odds ratio 3.89, p = 0.034) and anterior wall tumor location (odds ratio = 4.07, p = 0.037) were the predictors of postoperative urinary dysfunction. Compared with patients without risk factors, those with the two risk factors needed longer hospital stays (16 days vs. 30 days, p = 0.0022)., Conclusion: Male sex and anterior wall tumor location were the risk factors for urinary dysfunction after laparoscopic rectal surgery.

Introduction and Hypothesis: The objective was to compare postoperative urinary retention using the Babcock and Kelly clamps for retropubic midurethral sling (RPS) tensioning., Methods: This was a retrospective cohort of isolated RPS procedures from December 2010 through April 2016 by five fellowship-trained surgeons at two institutions. Slings were tensioned with a Babcock clamp by grasping a 3-mm midline fold of mesh (RPS-B) or a Kelly clamp as a spacer between the sling and suburethral tissue (RPS-K). Assessment of urinary retention included the primary outcome of postoperative catheterization and several secondary outcomes, including discharge home with a catheter, within 1 year of surgery. Analysis of covariance was used to compute the mean difference in duration of catheterization and log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI)., Results: We included 240 patients. The RPS-B group had a lower body mass index and was more likely to be menopausal, have had pelvic organ prolapse surgery, and have a lower maximum urethral closure pressure than the RPS-K group. The mean duration of catheterization was similar, as demonstrated by the crude (0.21 days [-0.30-0.71]) and BMI-adjusted (0.07 days [-0.41-0.55]) mean difference in duration of catheterization. The incidence of postoperative OAB symptoms was comparable between the groups (BMI-adjusted RR: 0.95 (0.80-1.1)), and the incidence of revision did not differ (p = 0.7)., Conclusions: The Babcock and Kelly clamp tensioning techniques appear comparable, with a low incidence of prolonged postoperative catheterization. Most catheters were removed on the day of the surgery. It is reasonable to tension retropubic midurethral slings with either method.

Introduction and Hypothesis: Studies have yet to examine the impact of day-of-surgery voiding trials on post-operative urinary retention in women undergoing obliterative and apical suspension procedures for pelvic organ prolapse. Our objective was to evaluate if time to spontaneous void after these procedures is shorter when a voiding trial is performed on the day of surgery compared with our standard practice of post-operative day 1., Methods: We conducted a randomized, parallel-arm trial in patients undergoing major pelvic floor reconstructive surgery. Women were randomized 1:1 to an early (4 h post-operatively on the day of surgery) or a standard (6 am on post-operative day 1) retrograde voiding trial., Results: A total of 57 women consented. Mean age and BMI were 65 ± 11 and 27.9 ± 4.4. Most women had stage III pelvic organ prolapse (77.2%). Groups had similar baseline characteristics. In the intention-to-treat analysis (n = 57), there was no difference in time to spontaneous void in the early versus standard voiding trial groups (15.9 ± 3.8 vs 28.4 ± 3.1 hours, p = 0.081). In the adjusted analysis using mutlivariable linear regression, an early voiding trial decreased the time to spontaneous void (abeta -2.00 h, p = 0.031) when controlling for vaginal packing and stage IV prolapse. In the per-protocol analysis, which excluded 4 patients for crossover, spontaneous void occurred 17 hours faster in the early voiding trial group (14.6 ± 3.7 vs 31.8 ± 2.9 hours; p = 0.022). Early voiding trial patients experienced ambulation sooner and more often than the standard group (p = 0.02)., Conclusions: A day-of-surgery voiding trial did not prolong catheter use after obliterative and apical suspension procedures.

Introduction and Hypothesis: We evaluated changes in voiding function at 3 months after laparoscopic sacrocolpopexy (LSC) for advanced pelvic organ prolapse (POP) patients and identified risk predictors for postoperative voiding dysfunction., Methods: Seventy-six patients with advanced POP who underwent LSC were enrolled in this retrospective cohort study. Pre- and postoperative objective voiding function was assessed by uroflowmetry plus postvoid residual (PVR) volumes. Voiding dysfunction was defined as a maximum flow rate (Q max ) < 15 ml/s, average flow rate (Q ave ) < 10 ml/s, or PVR > 50 ml. Statistical analyses were performed using paired-sample t tests, McNemar's tests, and multivariate regression analyses., Results: Thirty patients (39%) showed evidence of voiding dysfunction preoperatively, but two thirds of these patients were asymptomatic. Voiding dysfunction decreased significantly from baseline to 3 months after surgery (39% vs. 21%, p = 0.009), including a decrease among patients with Q ave  < 10 ml/s (32% vs. 17%, p = 0.043) and PVR > 50 ml (24% vs. 9%, p = 0.019). Voiding difficulty decreased significantly from baseline to 3 months after surgery (32% vs. 9%, p < 0.001); urgency and urinary incontinence symptoms did not exhibit significant improvement (p > 0.05). Multivariate analysis identified Q ave  < 10 ml/s as the independent predictor of postoperative voiding dysfunction [p = 0.014, odds ratio (OR) = 4.77, 95% confidence interval (CI) 1.37-16.54]., Conclusions: Preoperative voiding dysfunction is common among patients with POP and significantly improves at 3 months following LSC. A preoperative Q ave  < 10 ml/s was an independent risk factor for postoperative voiding dysfunction.

In young adults, acute motor axonal neuropathy and transverse myelitis rarely occur as associated conditions. Clinical reasoning, symptoms, laboratory and ancillary investigations (electroneurographic and radiological findings), should properly address the physician to the correct diagnosis.

Introduction and Hypothesis: Early voiding dysfunction (EVD) with urinary retention (UR) is a complication of midurethral sling (MUS) surgery. Management is not standardized. Our objective was to characterize management approaches at our center, and report outcomes including resolution of UR, persistent voiding dysfunction, and recurrent stress urinary incontinence (SUI)., Methods: All women requiring catheterization for ≥7 days after MUS surgery during the period March 2014 to 2016 were eligible for inclusion in this prospective study. The management plan for each patient was decided jointly by the surgeon and the patient. Questionnaires regarding urinary symptoms were administered at enrollment, and 3 and 6 months after surgery. The timing and type of any surgical intervention were recorded., Results: During the 2-year period, 31 women experienced EVD for ≥7 days after MUS surgery. At 6 months, complete data were available for 30 women (97%). Two management approaches were identified: "early mobilization" to loosen the MUS intact (in 10 patients), and continued catheterization with delayed sling lysis as needed (in 21 patients). In eight of the ten women in the early mobilization group, UR resolved after one intervention. Two required a second mobilization. For all women in this group, UR resolved after one or two procedures. In 11 of the 21 women in the continued catheterization group UR resolved without intervention. The other ten women in the continued catheterization group opted for sling lysis ≤6 months after MUS surgery. None of the women in the mobilization group reported SUI at 6 months in contrast to 9 of 20 (45%) in the planned continued catheterization group (p = 0.029). Seven of the nine women experiencing recurrent SUI had undergone sling lysis., Conclusions: Patients experiencing EVD after MUS surgery can be informed that UR will resolve in 50% with continued catheterization. Mobilization should be an option for those not comfortable with prolonged catheterization. Early intervention by mobilization may be associated with a lower risk of recurrent SUI, compared to continued catheterization and delayed sling lysis.

Introduction and Hypothesis: The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery., Methods: We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively., Results: Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 - 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H 2 O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 - 5.60, 1.39 - 2.91 and 1.10 - 3.21, respectively)., Conclusions: Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H 2 O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

Background: After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique., Methods: We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery., Results: One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %., Conclusions: LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

Pheochromocytomas of extra-adrenal origin are known as paragangliomas. Urinary bladder is the most common site of genitourinary paragangliomas. The variable functional status of these tumors presents a surgical challenge in their management by minimally invasive surgery. Robot-assisted partial cystectomy offers the advantage of minimal handling of tumor, early ligation of feeding vessels and easy suturing. We hereby report the feasibility and safety of robot-assisted surgery in the management of one such case.

Introduction and Hypothesis: The classic triad of dry eyes, mouth and vagina is known to most gynaecologists as pathognomonic of Sjögren's syndrome, but rheumatologists seldom consider vaginal symptoms. Our hypothesis was that women with Sjögren's syndrome would have an increased likelihood of postoperative voiding dysfunction, severe vaginal stenosis or poor response to anticholinergics compared with the general urogynaecology patient., Methods: All patients with Sjögren's syndrome were prospectively recorded from July 2007 to June 2015. Presenting complaint, pelvic examination findings, previous/subsequent pelvic surgery, voiding dysfunction and response to anticholinergics were noted. The denominator, all new urogynaecology patients, was prospectively recorded., Results: Fifteen patients were identified over 8 years (0.5 % of 2794 new presentations). Of the seven patients who had previously undergone surgery elsewhere, all had demonstrable pelvic tissue fibrosis; five had such severe fibrosis that no speculum could be passed. Anticholinergic medications were completely intolerable in 10/11 (91 %) women, and severe postoperative voiding dysfunction occurred in 6/9 (67 %) women. Only 2/15 (13 %) women were unaffected by fibrosis, postoperative voiding dysfunction or intolerance to anticholinergics., Conclusions: This audit demonstrates a substantial risk of vaginal stenosis, postoperative voiding dysfunction or severe intolerance to anticholinergics in women with Sjögren's syndrome.

Introduction and Hypothesis: One of the most commonly experienced postoperative complications of the tension-free vaginal tape procedure (TVT) is voiding dysfunction (VD). The aim of this retrospective study was to evaluate our incidence of postoperative VD, our results after tape mobilisation, and whether demographic data could predict VD., Methods: A total of 715 women underwent a TVT procedure without concomitant operative procedures. In the case of persisting VD transvaginal tape mobilisation was performed up to 3 weeks postoperatively. The vaginal incision was reopened and downward extraction with a clamp was performed. Demographic data were investigated to predict postoperative VD., Results: A total of 28 patients (3.9%) experienced VD. Seventeen patients (2.4%) underwent transvaginal tape mobilisation an average of 11.6 days (range 2-21) after the primary TVT procedure. No complications were observed in connection with the mobilisation. Eleven patients (1.5%) performed clean intermittent catheterisation (CIC) for a period of more than 1 day, with an average of 14.4 days (range 3-63). After tape mobilisation 16 women (94%) were relieved of their voiding dysfunction and were continent. One woman was somewhat incontinent after the procedure. Age, parity and previous caesarean section did not predict VD. Previous incontinence surgery might predict VD., Conclusions: The incidence of VD after the TVT procedure requiring tape mobilisation was 2.4%. Relief of the VD was obtained after tape mobilisation in all patients. Tape mobilisation is a safe and effective treatment for postoperative VD.

Aim of the Study: Overactive bladder occurs in up to 70% and underactive bladder in up to 50% of patients with Parkinson's disease (PD), which is thought to reflect an altered frontal-basal ganglia circuit. However, it is not clear how bladder disorder is related to motor function and to quality of life (QOL) in PD. We studied these relationships by conducting multiple regression (MR) and bivariate correlation (BV) statistical analyses., Methods: We recruited 58 PD patients, irrespective of the presence of bladder disorder: 35 men and 23 women of mean age 66.8 years, mean duration of the disease 5.4 years, and median score of Hoehn-Yahr stage 3. We administered a bladder questionnaire including two major types of lower urinary tract symptoms, 'overactive bladder (OAB)' and 'voiding difficulty,' in addition to a QOL index and a pressure-flow urodynamic study to detect detrusor overactivity (DO) during filling; and detrusor weakness, outlet obstruction, and post-void residuals (PVR) during voiding. We analyzed the results using the MR and BV methods., Results: (1) Motor impairment (by HY grades) was significantly related to detrusor weakness (P < 0.05 MR); voiding difficulty, OAB (P < 0.05 BV) (by de novo, levodopa honeymoon, and wearing-off); and voiding difficulty (P < 0.05 MR). (2) Bladder QOL was significantly related to OAB, increased bladder sensation (P < 0.05 MR) and voiding difficulty (P < 0.05 BV). (3) Male gender was significantly related to outlet obstruction, DO (P < 0.05 MR). (4) Age was significantly related to DO and PVR (P < 0.05 MR). Disease duration was significantly related to OAB (P < 0.05 MR)., Conclusion: From these results, detrusor weakness (relevant to motor impairment) and OAB (relevant to bladder QOL) are thought to be fundamental in PD. In contrast to the mechanism of OAB, the mechanism of detrusor weakness in PD remains unclear and warrants further exploration.

Introduction and Hypothesis: The objective of this study was to compare the histological characteristics of pathological specimens of excised midurethral sling mesh and surrounding vaginal tissue in patients who presented preoperatively with pain and/or exposure of mesh to patients who underwent mesh excision for voiding dysfunction without pain and/or erosion., Methods: This is a retrospective case-control study of women who underwent excision of midurethral sling mesh between 2008 and 2013. Three groups were identified: (1) voiding dysfunction without pain or exposure (control group), (2) pain and/or mesh exposure, and (3) voiding dysfunction with pain and/or mesh exposure. All original pathological specimens were rereviewed by one pathologist blinded to indication for excision and the previous pathology report. Degree of inflammation and fibrosis were recorded based on a 4-point scale along with the presence of giant cell reaction., Results: A total of 130 subjects met inclusion criteria: 60 (46.2 %) with voiding dysfunction only, 21 (16.2 %) with pain/erosion, and 49 (37.7 %) with both pain/exposure and voiding dysfunction. The voiding dysfunction only group was found to have significantly higher levels of inflammation, median grade 2 (1-3), compared to the other two groups with a p value of 0.007. There were no statistical differences in fibrosis and giant cell reaction between the three groups., Conclusions: Midurethral sling mesh excised for voiding dysfunction demonstrates elevated levels of inflammation compared to mesh that is excised for pain and/or exposure. The vaginal tissue fibrosis and giant cell reaction are similar in patients who undergo mesh excision for voiding dysfunction and pain, and/or mesh exposure.

Purpose: To evaluate the safety and efficacy of valgus mucosa anastomosis in posterior urethra reconstruction., Methods: We retrospectively reviewed the medical records of 116 patients who had undergone anastomotic repair of posterior urethral strictures between 2009 and 2013. Seventy-six patients underwent valgus urethral mucosa anastomosis (group A), and 40 underwent traditional end-to-end anastomosis (group B). The voiding status, complication rate, and adjuvant therapy were compared between the two groups. The clinical outcome was considered a failure when any postoperative intervention was needed., Results: Patient age ranged from 11 to 68 years (mean 38.2 ± 10.6). Follow-up was 5-59 months (mean 19.5 ± 13.2). The estimated urethral stricture length was 0.5-3.5 cm (mean 1.85 ± 0.40). Of all patients, the number of patients with simple stricture and complicated stricture were 47 and 69 respectively, and there was no significant difference in the complexity of stricture between group A and group B (60.5 vs. 57.5%, P > 0.05). Besides, there was no significant difference in the follow-up time and length of stricture between the two groups (31.6 ± 12.0 vs. 35.1 ± 14.8 months, P > 0.05). Compared to group B, the operation success rate in group A was greatly improved (92.1 vs. 80%, P < 0.05), while the incidence of complication was similar between the two groups (31.6 vs. 27.5%, P > 0.05)., Conclusions: The valgus urethral mucosa anastomosis could significantly improve the operation success rate of end-to-end anastomosis, reduce the stricture recurrence rate, improve the long-term urination function, and not increase the incidence of complications. So, valgus urethral mucosa anastomosis is an easy, effective and reliable urethral anastomosis technique.

The overactive bladder (OAB) is a well-known and common urologic condition. However, the apparent opposite syndrome to the OAB, the underactive bladder (UAB), remains an enigma. Underactive bladder syndrome is complex condition that shares symptoms with other prevalent urologic diagnoses. UAB is not a pure condition-it is not the result of any single factor, but rather, it is multifactorial. As a result, UAB may overlap with OAB, bladder outlet obstruction, or even occur with no symptoms or associated diseases. To make it yet more challenging, in the elderly, detrusor hyperreflexia/impaired contractility (DHIC) is a condition that has the pathological elements of both OAB and UAB and is also common. I hypothesize that UAB and OAB may not be an entirely separate disease entity. Instead, chronic untreated or treatment refractory OAB--due to neurological diseases such as diabetes, bladder outlet obstruction or aging sarcopenia and frailty--may progress to DHIC and, finally, UAB. The progression of OAB to UAB hypothesis suggests that early education, behavioral modification and medical treatment may alter and/or prevent progression to UAB.

Purpose: In view of the limited information on neurogenic lower urinary tract dysfunction (NLUTD) after spinal cord injury (SCI) in the literature, this study aimed to investigate the complication rate of NLUTD after SCI and to describe the clinical management of NLUTD in Taiwan., Methods: A cross-sectional study was conducted using the National Health Insurance Research Database of Taiwan from which patients newly diagnosed with SCI during 2006-2008 were extracted. Records of diagnosis, prescriptions, and procedures for patients were retrieved to identify NLUTD cases. The utilization of medical treatments including pharmacotherapy and procedures such as intermittent and indwelling catheters was analyzed., Results: A total of 941 eligible SCI patients were identified, with a mean age of 48.4 (±18.5), of which 575 (61.1 %) were male, and 500 (53.1 %) were with cervical SCI. By the end of 1-year follow-up, 165 (17.5 %) had developed NLUTD. The characteristics were mostly similar between the NLUTD and non-NLUTD groups except in age and length of stay (LOS) in hospitals, where patients with NLUTD were 7.5 years old and had 2.15-month-longer LOS. Over 80 % of NLUTD patients received urinary catheterization, with approximately half also receiving pharmacotherapy., Conclusions: This is the first study using nationwide datasets to evaluate the overall complication rate of NLUTD associated with SCI, which is shown to be lower than previously reported. While various treatment options are available, urinary catheterization is the most common treatment for NLUTD.

This case report describes laparoscopic urethrolysis followed by trans-obturator tape sling insertion for voiding dysfunction after colposuspension. A 50-year-old patient presented with predominant stress incontinence of urine 14 after Burch colposuspension. There was no anterior vaginal wall prolapse on examination and urodynamic assessment confirmed voiding dysfunction in the absence of urodynamic stress incontinence. Clean intermittent self-catheterisation was tried, but failed to improve the patient's symptoms. Laparoscopic urethrolysis was carried out, leading to the relief of voiding dysfunction, but was followed by recurrence of stress incontinence. A trans-obturator tape sling was subsequently inserted with significant improvement in stress incontinence and the patient was discharged.

"Female genital circumcision" or "female genital mutilation", as it is called more often, is an operation that is primarily carried out in Africa. Owing to migration, physicians are increasingly confronted with this issue in Western countries as well. A range of negative effects may result from this operation and this article aims to address consequences for female pelvic health. Special emphasis is placed on urogynaecological health consequences; in particular, on "voiding difficulties", "recurrent urinary tract infections" and "vesicovaginal fistula". All of these occur mostly in infibulated women, i.e. in women whose genitalia are sealed by the most severe form of circumcision. Some of the problems that may emerge as a result of the operation can be resolved by defibulation (i.e. surgical reopening of the sealed vulva). Female genital circumcision is a sensitive topic even in the area of research and reliable data are therefore scarce.

Voiding dysfunctions are common neurological complications after a stroke, yet there are few urodynamic studies of patients with cerebellar stroke. We report the video urodynamic findings of 15 patients with cerebellar stroke, including eight patients with ischemic and seven with hemorrhagic stroke. Their mean age was 75 ± 13.4 years and the mean interval from stroke to video urodynamic study was 11.2 ± 17.9 months. At urodynamic study, four (50 %) patients with ischemic stroke had urinary incontinence as did two (28 %) patients with hemorrhagic stroke. Detrusor overactivity (DO) was found in eight (53 %) patients, dyssynergic urethral sphincter in six (40 %), and nonrelaxing urethral sphincter in seven (47 %). DO occurred in six (75 %) of patients with ischemic stroke and in two (28.6 %) of patients with hemorrhagic stroke (p = 0.072). While DO was not found in five of the 15 patients within 2 months after the stroke, it was more frequently detected in eight (80 %) of the 10 remaining patients 2 or more months after stroke (p = 0.007). Four (80 %) of the five stroke patients had nonrelaxing sphincter and urinary retention within 2 months after stroke. Two or more months after their strokes, coordinated sphincter function was noted in two (20 %) patients and dyssynergic sphincter was found in six (60 %); two (20 %) remained with nonrelaxing sphincter. Thus, lower urinary tract dysfunction caused by cerebellar stroke may change with time. Knowledge of video urodynamic findings should help us better manage voiding dysfunction in patients with cerebellar stroke.

Background: Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial., Methods: Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36., Results: The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107-188] vs. conventional, 146.5 h [115-183], p = 0.47; 7.5 days [7-11] vs. 8.0 days [7-10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups., Conclusions: This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).

Background: Preoperative radio(chemo)therapy (pR(C)T) significantly reduces the local recurrence risk and is therefore recommended in stage II/III rectal cancer. However, this multimodal treatment approach may be associated with late adverse effects. To determine the impact of pR(C)T on long-term anorectal, sexual, and urinary function, we performed a systematic review and meta-analysis., Methods: PubMed, Embase, and the Cochrane Library were systematically searched for studies reporting on long-term functional outcome after rectal cancer resection with pR(C)T. Only studies that reported anorectal, sexual, and/or urinary function after rectal cancer resection in TME-technique with pR(C)T were eligible for inclusion., Results: Twenty-five studies, including 6,548 patients, were identified. Methodological quality of the eligible studies was low. The majority of studies reported higher rates of anorectal (14/18 studies) and male sexual dysfunction (9/10 studies) after pR(C)T. Few studies examined female sexual dysfunction (n = 4). Meta-analysis revealed that stool incontinence occurred more often in irradiated patients (risk ratio (RR) = 1.67; 95 % confidence interval (CI), 1.36, 2.05; p < 0.0001) and manometric results were significantly worse after pR(C)T (mean resting pressures (weighted mean difference (WMD) = 15.04; 95 % CI, 0.77, 29.31; p = 0.04) and maximum squeeze pressures (WMD = 30.39; 95 % CI, 21.48, 39.3; p < 0.0001)). Meta-analysis of erectile dysfunction revealed no statistical significance (RR = 1.41; 95 % CI, 0.74, 2.72; p = 0.3). Six of eight studies and meta-analysis demonstrated no negative effect of pR(C)T on urinary function (RR = 1.05; 95 % CI, 0.67, 1.65; p = 0.82)., Conclusions: Although quality of studies on long-term functional outcome is limited, current evidence demonstrates that pR(C)T negatively affects anorectal function after TME.

Introduction and Hypothesis: Long-term outcome data exist with Gynecare TVT tension-free support for incontinence (TVT), yet few comparisons have been made to newer retropubic sling delivery systems, especially with regards to urethrolysis for postoperative voiding dysfunction. Our objective was to compare the odds of urethrolysis for the treatment of voiding dysfunction between two retropubic sling systems., Methods: We performed a case-control study comparing the risk of urethrolysis between TVT versus the Bard ALIGN Urethral Support System (Bard Align). We identified surgical procedures described as urethrolysis, sling revision, loosening, or lysis performed for the treatment of voiding dysfunction by urogynecologists at Duke University between January 2007 and June 2011. Slings placed at outside institutions were excluded. Controls were matched for both concomitant prolapse procedures and academic year., Results: Of 818 total slings placed during the study period, there were 28 (3.4 %) urethrolysis cases, which were matched to 84 controls. Among urethrolysis cases, 6/28 (21.4 %) had received TVT, while 22/28 (78.6 %) had received Bard Align slings. Of the 84 matched controls, 30/84 (35.7 %) had undergone TVT and 54/84 (64.3 %) had undergone Bard Align. There was no significant difference in the odds of urethrolysis following the use of TVT or Bard Align [odds ratio (OR) 2.00, 95 % confidence interval (CI) 0.74-5.50]. In a conditional logistic regression model, which adjusted for age, body mass index, prior anti-incontinence or prolapse surgery, and postvoid residual, there remained no significant difference in odds of urethrolysis between the two sling types (OR 1.50, 95 % CI 0.42-5.33)., Conclusions: Despite different instrument designs, there was no significant difference in the risk of urethrolysis following TVT or Bard Align retropubic sling.

Introduction and Hypothesis: Controversy continues over the effectiveness of sling incision, which is the most common operative approach to treating complications following suburethral sling insertion. This retrospective analysis assessed the indications for sling incision and patient outcomes regarding resolution of complications and stress urinary incontinence., Methods: A review was conducted of the medical records of women who underwent sling incision between 2003 and 2010. Data such as surgical indications, ultrasound findings and medical outcomes were extracted from 198 records, and descriptive and inferential statistical methods of analysis were used., Results: In the 198 patients eligible for study inclusion, the primary reasons for sling incision were overactive bladder (68 %), voiding dysfunction (61 %), and recurrent urinary tract infections (53 %). Additional complications included dyspareunia (18 %), chronic pelvic pain (17 %), and sling exposure (15 %). Sling incision led to immediate postoperative cure of voiding dysfunction in 97 % of patients. Cure rates for overactive bladder and dyspareunia were 60 % and 94 % respectively. Chronic pelvic pain was resolved in 82 % of cases and all cases of sling exposure were cured. Eighty-five (61 %) of the 140 patients who were continent before sling incision developed recurrent stress urinary incontinence (SUI) postoperatively., Conclusions: These findings indicate that sling incision can be highly successful in improving voiding dysfunction and dyspareunia, and moderately successful in curing overactive bladder and chronic pain. However, SUI may recur in more than 60 % of the patients undergoing sling incision. Consequently, patients being considered for a sling incision procedure should be informed about this possible complication.

Introduction and Hypothesis: We used the Valentini-Besson-Nelson (VBN) mathematical micturition model to analyze the potential obstructive effect of a 7-F transurethral catheter on the voiding process during intubated flow (IF) in women. Our hypothesis was that incomplete sphincter relaxation leads to residual sphincter pressure., Methods: We reviewed a urodynamic database of women referred for evaluation of lower urinary tract dysfunction. Exclusion criteria were neurological disease or grade ≥2 prolapse. Eligible women underwent free uroflow (FF-1) before cystometry, an IF (7-F urethral catheter), and a second FF (FF-2) at the end of the session. Interpreted flows were restricted to voided volumes ≥100 ml and continuous flow patterns. Analysis of FF and IF was made using the VBN model., Results: Among 472 women, 157 met the inclusion criteria. The effect of the urethral catheter was geometric only in 60 (38.2 %) patients. An additional effect, identified as incomplete sphincter relaxation, was observed in 97 (61.9 %) patients. Among this second group, the same residual sphincter excitation was found for 30 (30.97 %) patients during FF-2., Conclusion: When comparing IF with FF with the VBN model, the decrease in maximum flow rate (Q(max)) did not appear to result only from the geometric effect of the catheter but from incomplete sphincter relaxation during voiding, possibly because of patient's anxiety or a urethral reflex induced by the presence of the catheter. These findings emphasize the need to perform an FF before the IF to strengthen the reliability of conclusions of a urodynamic investigation.

Introduction and Hypothesis: The aim of this study is to report a novel understanding of the urodynamic parameters used to diagnose iatrogenic female obstruction. There is no consensual definition of infravesical obstruction in women. Numerous criteria were designed with arbitrary cutoff values with poor clinical correlation. In order to determine the urodynamic profile of infravesical female obstruction we restricted our analysis to women who acquired voiding disturbances after being submitted to stress urinary incontinence (SUI) surgery., Methods: A total of 302 women developed obstructive symptoms or voiding difficulties after SUI operations: 176 cases had had Kelly-Kennedy operations (58.2 %), 50 had had Burch operations (16.5 %), 37 (12.2 %) had had anterior colporrhaphy + abdominal (Burch) operations, 33 (10.9 %) had had sling operations, and 8 (2.6 %) had had Marshall-Marchetti operations. Obstructive urinary symptoms started in 1-120 days after the operation and urodynamic evaluations were done after various periods of time (median 18.4 months). Clinical presentations varied widely with irritative symptoms predominating the picture., Results: Five patterns of pressure-flow relationships could be identified: (1) elevated pressure and poor flow (7.2 %), (2) normal pressure and poor flow (41.5 %), (3) normal pressure and flow associated with prolonged flow time (24.2 %), (4) poor detrusor contraction and elevated residual volume (12.9 %), and (5) elevated pressure and high flow (14.5 %). No relationship was established amongst the group and the Urinary Distress Inventory questionnaire., Conclusions: Infravesical obstruction in women does not fit a single model. As suggested, obstruction in women must be based on broad clinical pictures and urinary complaints.

We present a case of iatrogenic neonatal urinary ascites following antenatal amnioreduction in one of the monochorionic diamniotic recipient twin 2 of twin-to-twin transfusion syndrome (TTTS). He had ileal perforation following postnatal abdominal paracentesis. The patient had an uneventful recovery following exploratory laparotomy, resection of perforated segment of ileum with end-to-end anastomosis and open vesicostomy with subsequent closure of the vesicostomy.

Introduction and Hypothesis: Urogynaecological assessment routinely includes determination of postvoid residual urine volume (PVR). This study was designed to generate a formula for determining PVR by translabial ultrasound (US)., Methods: This was an observational study using imaging data obtained during urodynamic testing between July 2009 and November 2010. Bladder dimensions were determined by translabial US (midsagittal plane) and blinded against PVR on catheterisation. The relationship between PVR and bladder dimensions was modelled using linear regression. Predictive performance was quantified using Pearson's correlation and R (2) statistic., Results: In 207 individuals, 243 PVRs were obtained by catheterisation (0-650 ml). An optimal regression model comprised the product of height and depth US measurements and a coefficient of 5.59 [95 % confidence interval (CI): 5.41-5.76, p < 0.0001)] This regression equation yielded an R(2) = 0.94; Pearson's correlation was 0.97., Conclusions: Translabial US is a convenient and accurate method for measuring PVR. We propose the formula height × depth × 5.6 = postvoid residual in millilitres.

Introduction and Hypothesis: The objective of the study was to compare office rigid cystoscopy (RC) versus flexible cystoscopy (FC) in women., Methods: This was a prospective randomized trial comparing FC to RC. Aims were to assess 1-week post-procedural complications, compare procedure pain scores, and to assess physician perception of patient discomfort. Pain scores were assessed by visual analogue scale (VAS) and 5-point verbal descriptor scale (VDS). Chi-square was used for categorical comparison and t tests or Wilcoxon test for continuous variables., Results: One hundred women were enrolled. The mean age of participants was 59.7 years (± SD 14.6), and 91 % were Caucasian. This was the first cystoscopy for 86 % of participants. On the 1-week post-procedure questionnaire (85 % response rate), participants in the FC group reported urinary frequency more often than in the RC group (p = 0.041). The FC group reported urgency with urination lasting 1-2 days (p = 0.030) and burning with urination lasting >3 days (p = 0.026), more than the RC group. These symptoms did not persist at 7 days. The duration of the procedure was slightly faster for the FC group (4.6 ± 1.8 min vs 5.7 ± 3.4 min, p = 0.046). Median VAS scores were 0.9 (0.1-2.72) for the FC group and 0.5 (0-2.4) for the RC group (p = 0.505). There were no significant differences between patient or physician perception of pain in either group., Conclusions: Urinary frequency and duration of urinary burning post procedure occurred more frequently in the FC group, although these symptoms were transient. Both office FC and RC are generally well tolerated in women with overall low morbidity.

A 51-year-old white woman, gravida 4, para 3-0-1-3 referred to our urogynecology clinic for evaluation of questionable symptomatic pelvic organ prolapse was found to have a periurethral mass with associated urinary urgency. She underwent transvaginal excision of this mass, and pathology revealed angioleiomyoma. Her urinary urgency has resolved after surgery. No prior periurethral angioleiomyoma has been reported in female patients.

Background: Sexual and urinary dysfunction is an established risk after pelvic surgery. Studies examining sexual and urinary function following laparoscopic and open rectal surgery give conflicting evidence for outcomes. The purpose of this study was to analyse the impact of the surgical technique on functional outcomes following laparoscopic or open resection for rectal cancer patients in a high-volume laparoscopic unit., Methods: All patients who underwent elective laparoscopic or open surgery for rectal cancer between September 2006 and September 2009 were identified from a prospectively collated database. Validated standardized postal questionnaires were sent to surviving patients to assess their postoperative sexual and urinary function. The functional data were then quantified using previously validated indices of function., Results: A total of 173 patients were identified from the database, of whom 144 (83 %) responded to the questionnaire-based study. Seventy-eight respondents had undergone laparoscopic rectal resection (49 men and 29 women), and 65 had an open procedure (41 men and 24 women). Both open surgery and laparoscopic surgery were associated with deterioration in urinary and sexual function. With regard to urinary function, there was no difference in the deterioration in open and laparoscopic groups in either gender. With regard to sexual function, in males one component of sexual function, namely, the incidence of successful penetration, showed less deterioration in the laparoscopic group (p = 0.04). However, in females, laparoscopic surgery was associated with significantly better outcomes in all aspects of sexual activity, specifically sexual arousal (p = 0.005), lubrication (p = 0.001), orgasm (p = 0.04), and the incidence of dyspareunia (p = 0.02)., Conclusion: Laparoscopic total mesorectal excision for rectal cancer is associated with significantly less deterioration in sexual function compared with open surgery. This effect is particularly pronounced in women.

Introduction: Parkinson's disease is an extrapyramidal neurological disorder. Although motor symptoms are a predominant feature of the condition, non-motor symptoms have also been recognized. Urinary symptoms are frequently present in patients affected with Parkinson's disease (PD). Symptoms such as urgency, frequency, nocturia and urge incontinence significantly impact the patient's quality of life. We discuss the urinary dysfunction seen in patients with Parkinson's disease and consider the pathophysiology, important differentials, the investigations and management options for such patients., Materials and Methods: An extensive search was performed using the PubMed(®)/EMBASE(®) databases to identify the available literature on urinary disturbances and Parkinson's disease. Reference was also made to current national guidelines on Parkinson's disease., Results: Urinary disturbances are frequently observed in sufferers of Parkinson's disease resulting in significant impact to the individual's quality of life. Studies report that storage symptoms are present in 57-83% of patients, whereas voiding symptoms are seen in 17-27% patients. Out of all the urinary symptoms, nocturia is the most common complaint in >60% patients with PD. Urgency occurs in 33-54% of patients, whilst frequency is experienced by 16-36% of patients. Detrusor overactivity (DO) is the commonest cystometric abnormality in patients with PD. The rate of neurogenic DO in patients with PD is 45-93%. The main differential to consider is Multiple System Atrophy (MSA) in which all patients are ultimately afflicted with urinary disturbance. It is well recognized that patients initially diagnosed with PD may in fact have MSA, and it is important to distinguish the two as their urological management is different. Patients presenting with refractory LUTS with concurrent PD should undergo full urodynamic investigation including cystometry, flowmetry and ultrasonography before treatment is initiated., Discussion: Referral to a urologist is advised in those with persistent or refractory urinary complaints. Urodynamic evaluation allows determination of the underlying bladder disorder; however, post-void residuals suffice in the uncomplicated patient. The pathophysiology of urinary dysfunction and current investigation and treatment modalities are discussed.

Introduction and Hypothesis: Iatrogenic female urethral obstruction resulting from sling operations may be related to surgical inexperience and must be better understood. Although there are no widely recognized parameters for this type of study, a single-surgeon consecutive series offers an opportunity to study the role of expertise in sling operations over time., Methods: This study consecutively examined 176 women who underwent an autologous fascial sling procedure. Postoperative urethral obstruction was identified by the occurrence of voiding dysfunctions. Clinically obstructed patients were invited to undergo a postoperative urodynamic evaluation after 3 months. To enable comparison, patients were placed into 6-month groups according to the time of surgery., Results: A total of 159 cases were evaluated with a mean follow-up time of 32.4 ± 13.4 months. Stress continence was cured in 97.5% of cases. Although 29 patients were identified as obstructed, only 20 underwent a postoperative urodynamic evaluation. Only five of the clinically obstructed cases showed a high P(det)Q(max). All of the other cases met one or more of the non-classic parameters linked to obstruction. Overactive bladder was present in 14 (63.6%) of the obstructed cases. Iatrogenic urethral obstruction was more common among the early cases (30.4%) than among the later ones (5%) (P < 0.001). Postoperative urodynamic evaluation showed a trend toward obstruction on pressure flow studies., Conclusions: Autologous fascial sling operations require expertise and involve a clear surgical learning curve. Iatrogenic obstruction in females does not fit a single model and may be difficult to recognize. Obstruction in females must be identified through clinical indicators and postoperative urinary complaints rather than the high detrusor pressure observed in men. Furthermore, iatrogenic female obstruction can probably be minimized but not eliminated.

We present the case of a female aged 16 years, suffering from cyclical menouria for the last 3 years. Clinical examination revealed the absence of a vagina. Cystoscopy performed while the patient was having menouria revealed an orifice (10 × 8 mm) in the supratrigonal region; blood clots were entering the urinary bladder through this orifice. Magnetic resonance imaging of the pelvis depicted a fluid-filled longitudinal tract distal to the uterus (which was the upper vagina), between the cervix and the bladder. Diagnostic laparoscopy confirmed the presence of a uterus, both ovaries, and the tubal structures. Exploratory laparotomy, correction of the fistulous tract, and sigmoid vaginoplasty were performed. The distal part of the fistulous tract (urinary bladder end) was anastomosed to the proximal end of the sigmoid neo-vagina. The patient is doing well as per her last follow-up at 6 months. She has started menstruating per neo-vagina.

Introduction and Hypothesis: The aim of the present study was to assess the relationship between lower urinary tract symptoms, anatomical findings, and baseline characteristics in women with pelvic organ prolapse (POP)., Methods: A cross-sectional observational study was performed, enrolling consecutive women seeking cares for lower urinary tract symptoms (LUTS) with evidence of POP. Data regarding baseline characteristics, LUTS, and physical examination were gathered for each patient. Multivariate analysis (multiple linear regression (MLR)) and artificial neural networks (ANNs) were performed to design predicting models., Results: A total of 1,344 women were included. Age, BMI, pelvic organ prolapse quantification (POP-Q) stage I, and previous surgery for urinary incontinence resulted predictors of urgency and stress incontinence. POP-Q stages III-IV were related to voiding dysfunction and POP symptoms. Age, BMI, and menopausal status resulted predictors for sexual dysfunction. Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLRs in identifying predictors of LUTS., Conclusions: LUTS result from a fine interaction between baseline characteristics and anatomical findings. ANNs are valuable instrument for better understanding complex biological models.

Background: Urinary and sexual dysfunctions are frequent after surgery for rectal cancer. Total mesorectal excision (TME) improves local recurrence and survival rates, and does not hamper recognition and sparing of hypogastric and pelvic splanchnic nerves. It is not known how laparoscopic rectal resection could change functional complication rates., Materials and Methods: From a global series of 1,216 laparoscopic interventions for colorectal diseases, 35 cases of males less than 70 years old, undergoing rectal resection and TME for a T1-3M0 medium and low rectal cancer were selected. Urinary and sexual functions after the operations were retrospectively recorded by means of specific tools (International Prostate Symptom Score (IPSS) and IIEF questionnaires, respectively)., Results: None of the patients necessitated permanent or intermittent catheterization. More than half the patients had no complaints about urinary functions; about one third had nocturia; 72% of the patients had an IPSS less that 10, and no case of IPSS worse that 31 was recorded. Sexual desire was reduced and spontaneous erectile function was impaired in almost half the cases, while induced erections were possible in about 90% of cases; about 70% of patients still had the possibility of penetration and a normal ejaculation and orgasm after the intervention., Discussion and Conclusions: The present series confirms previous data and contribute to the creation of a benchmark specifically related to the laparoscopic approach to which surgeons should face when informing the patients before the operation. While severe urinary dysfunction is rare, sexual impairment remains a serious concern after rectal resection with TME.

Introduction and Hypothesis: The optimal duration of urethral catheterization during and after pelvic reconstructive surgery is not established. This study investigated the optimal duration of urinary catheterization in patients undergoing anterior vaginal repair with or without other vaginal surgeries., Methods: A total of 90 patients were included from April 2007 to March 2008. They were randomly divided into 2, 3, and 4 days urinary catheterization groups based on the color of the questionnaire papers they blindly chose. After catheter removal, the amount of post-void residual urine was used to measure the efficacy of bladder emptying. Differences between groups were determined using Chi-square test, Fisher's exact test, or Kruskal-Wallis test, as appropriate., Results: No significant differences were found in the amount of post-void residual urine between the three catheterization groups., Conclusions: Our findings suggest that the duration of urethral catheterization after anterior colporrhaphy need not exceed 2 days.

Menouria due to congenital vesicovaginal fistula is rare entity. We report a case of a 22-year-old female who presented with menouria. On evaluation, she had congenital vesicovaginal fistula and obstructing complete vaginal septum. McIndoe vaginoplasty and fistula repair through vaginal route was performed.

Introduction and Hypothesis: To determine risk factors for sling revision after midurethral sling (MUS) placement., Methods: This multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999-2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision., Results: Of the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32-5.79; p = 0.004) retropubic sling type (OR = 2.28, 95% CI 1.08-4.78; p = 0.04) and concurrent surgery (OR = 4.88, 95% CI 2.16-11.05; p < 0.001), Conclusions: This study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.

Introduction and Hypothesis: To compare long-term lower urinary tract dysfunction after radical hysterectomy in patients with or without early postoperative voiding dysfunction., Methods: Thirty patients at least 2 years after radical hysterectomy were evaluated with multichannel urodynamic studies. Fifteen patients (group A) had early postoperative voiding dysfunction (required urethral catheterization more than 1 month), and 15 patients (group B) had no early postoperative voiding dysfunction., Results: Overall voiding dysfunction was more prevalent in group A than group B (73.3% versus 33.3%, p > 0.05). In particular, high postvoid residual urine and abdominal straining increased significantly in group A (40% versus 0% and 60% versus 13.3%, respectively). Total and all domains scores from Urogenital Distress Inventory and Incontinence Impact Questionnaire were not different between both groups., Conclusion: High postvoid residual urine and abdominal straining increased significantly in patients with early postoperative voiding dysfunction without impairment on quality of life.

Background: Chronic (normotensive or low pressure) hydrocephalus is characterized clinically by gait disturbance, cognitive and urinary impairment, known as Hakim's triad. Nothing has been reported about impairment in sexual function, which could involve both the patient and the patient's partner., Methods: Out of 97 patients undergoing shunt placement for chronic hydrocephalus, 28 male patients (28.8%) referenced sexual dysfunction before operation. In these cases, we performed a preoperative and postoperative survey of sexual activity., Results: In the preoperative period, all 28 patients reported having no sexual activity or arousal, from 2 to 4 years before the operation. Following shunt placement, 22/28 (78.5%) of patients regained variable sexual desire within a period ranging from 3 to 8 weeks, affording normal sexual activity with their partner., Conclusions: Sexual dysfunction can be part of the very early clinical background in patients with Hakim's triad and neuroradiological imaging compatible with chronic hydrocephalus. Restoration of sexual ability and arousal should be considered among the postoperative goals in these cases, together with improvements in cognition, gait, and urinary continence.

Background: Urinary and sexual dysfunction are potential complications of rectal surgery for cancer. This study retrospectively evaluated the frequency of such complications after laparoscopic total mesorectal excision (LTME) with autonomic nerve preservation., Methods: For this study, 50 men younger than 75 years who underwent radical LTME for mid and low rectal cancer were followed up for at least 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life., Results: Sexual desire was maintained by 55.6%, ability to engage in intercourse by 57.8%, and ability to achieve orgasm and ejaculation by 37.8% of the patients. Distance of the tumor from the anal verge and adjuvant or neoadjuvant treatments were the significant predictors of poor postoperative sexual function. Seven patients (14%) presented transitory postoperative urinary dysfunction, all of whom were medically treated. Tumor stage and distance from the anal verge were independently associated with the postoperative global International Prostatic Symptom Score (IPSS). No differences were observed in urinary quality of life., Conclusions: In this series, LTME did not reproduce or improve on sexual and urinary dysfunction outcomes obtained in the best open TME series. Further trials are needed to evaluate functional outcome in rectal cancer patients.

Background: Bladder neck contracture (BNC) following prostatectomy has been reported in 0.5-32% of cases. While the etiology of a BNC is unclear, several factors have been associated with this complication, including blood loss, devascularization of bladder neck tissue, poor mucosal apposition and urinary extravasation. To study the impact of urinary extravasation on BNC formation, we used postoperative drain output as a surrogate measure for anastomotic leakage., Methods: All patients undergoing a radical retropubic prostatectomy (RRP) or a robotic assisted radical prostatectomy (RARP) from January 2000 to April 2006 have been entered into a prospective review board-approved database. All RRP patients had their anastomosis performed in an interrupted fashion using six monofilament 2-0 sutures. All robotic-assisted radical prostatectomy anastomoses were performed in a running fashion using 2-0 monofilament sutures. A single, closed suction Jackson Pratt drain was placed over the surgical bed at the conclusion of the case. Post-operative drain outputs were recorded. All patients were evaluated at 3, 6, 9, 12 and 24 months post-operatively. All patients who reported a diminished urinary stream or incontinence were evaluated by office cystoscopy. The inability to navigate an 18 French cystoscope through the bladder neck was defined as a bladder neck contracture., Results: A total of 576 patients underwent a radical prostatectomy over this time span. Complete records were available for 535 (93%) of these patients. There were 21 bladder neck contractures (3.9%) overall. The post-operative drain output ranged from 5-5,465 ml (median 119 ml). Eight patients who had drain outputs less than 119 ml developed a BNC while 13 BNC developed in patients with Jackson Pratt drain output > 119 ml (P = 0.343). In patients who underwent an open RRP, 19/424 (4.5%) developed contractures while 2/108 (1.9%) RARP patients developed a BNC (P = 0.105)., Conclusion: The amount of post-operative drain output is not statistically associated with the development of a bladder neck contracture.

In an open-label extension of a randomized, double-blind clinical trial, the long-term efficacy and tolerability of a fixed combination of 160 mg Sabal fruit extract WS 1473 and 120 mg Urtica root extract WS 1031 per capsule (PRO 160/120) were investigated in elderly men with moderate or severe lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Two hundred and fifty-seven patients were randomly treated with 2 x 1 capsule/day PRO 160/120 or placebo for 24 weeks, followed by a 24-week control period and a 48-week follow-up period in which all patients received PRO 160/120. Efficacy measures included the assessment of LUTS [International Prostate Symptom Score ((I-PSS) self-rating questionnaire] and uroflow and sonographic parameters. Two hundred and nineteen subjects participated in the follow-up. Between baseline and end of observation (week 96) the I-PSS total score was reduced by 53% (P < 0.001), peak and average urinary flow increased by 19% (P < 0.001), and residual urine volume decreased by 44% (P = 0.03). The incidence of adverse events during follow-up was one in 1,181 treatment days; in only one event a causal relationship with intake of PRO 160/120 could not be excluded. Treatment with PRO 160/120 thus provides a clinically relevant benefit over a period of 96 weeks.

We report a case of parameatal urethral cyst in a 15-year-old boy which is a very rare congenital anomaly. The cyst recognized at infancy but the boy presented to our clinic at the age of 15 when the mass was grown enough to cause spraying of urine and poor cosmesis. Complete excision of the cyst with total removal of the epithelium is the required for treatment and prevention of recurrence.

Background: Although sporadic studies have described temporary external cerebrospinal fluid (CSF) lumbar drainage as a highly accurate test for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH) patients, a more recent study reports that the positive predictive value of external lumbar drainage (ELD) is high but the negative predictive value is deceptively low. Therefore, we conducted a prospective study in order to evaluate the predictive value of a continuous ELD, with CSF outflow controlled by medium pressure valve, in NPH patients., Method: Twenty-seven patients with presumed NPH were admitted to our department and CSF drainage was carried out by a temporary (ELD) with CSF outflow controlled by a medium pressure valve for five days. All patients received a ventriculoperitoneal shunt using a medium pressure valve based upon preoperative clinical and radiographic criteria of NPH, regardless of ELD outcome. Clinical evaluation of gait disturbances, urinary incontinence and mental status, and radiological evaluation with brain CT was performed prior to and after ELD test, as well as three months after shunting., Findings: Twenty-two patients were finally shunted and included in this study. In a three-month follow-up, using a previously validated score system, overall improvement after permanent shunting correlated well to improvement after ELD test (Spearman's rho = 0.462, p = 0.03). When considering any degree of improvement as a positive response, ELD test yielded high positive predictive values for all individual parameters (gait disturbances 94%, 95% CI 71%-100%, urinary incontinence 100%, 95% CI 66%-100%, and mental status 100%, 95% CI 66%-100%) but negative predictive values were low (< 50%) except for cognitive impairment (85%, 95% CI 55%-98%)., Conclusion: This study suggests that a positive ELD-valve system test should be considered a reliable criterion for preoperative selection of shunt-responsive NPH patients. In case of a negative ELD-valve system test, further investigation of the presumed NPH patients with additional tests should be performed.