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Purpose: We assessed the year-to-year consistency of outcomes in patients with urinary incontinence due to neurogenic detrusor overactivity who completed 4 years of onabotulinumtoxinA treatment., Materials and Methods: Eligible patients who completed a 52-week phase 3 trial of onabotulinumtoxinA for urinary incontinence could enter a 3-year open label extension study of onabotulinumtoxinA 200 or 300 U administered as needed for symptom control. This analysis focused on 227 patients who completed the 4-year study. Outcomes assessed by year of treatment included mean treatments per year, mean change from baseline at week 6 in urinary incontinence episodes per day and the I-QOL (Incontinence Quality of Life) total summary score, the proportion of patients with 50% or greater and 100% reductions in urinary incontinence episodes per day, duration of effect and adverse events., Results: Patients reported 4.3 urinary incontinence episodes per day at baseline and received 1.4 to 1.5 onabotulinumtoxinA treatments per year. The decrease in urinary incontinence following onabotulinumtoxinA consistently ranged from -3.4 to -3.9 episodes per day across 4 years. A high proportion of patients achieved 50% or greater and 100% urinary incontinence reductions in each year (range 86.6% to 94.1% and 43.6% to 57.4%, respectively). Consistent and clinically relevant improvements in I-QOL scores were observed in each treatment year. The overall median duration of effect of onabotulinumtoxinA was 9.0 months or greater (range 3.0 to 49.2) and 26.0% or more of patients experienced a duration of effect of 12 months or greater. The most common adverse event was urinary tract infection with no increased incidence with time., Conclusions: Patients with neurogenic detrusor overactivity who completed 4 years of onabotulinumtoxinA treatment experienced a consistent duration of treatment effect and year-to-year improvements in urinary incontinence and quality of life with no new safety signals., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The bladder effects of isoprenaline, and selective β₁ and β₂-adrenoceptor agonists reported in early studies suggest that bladder β-adrenoceptors are atypical. Since there is a lack of alternatives to antimuscarinics in the treatment of overactive bladder symptoms, there has been an intensive search for new drug targets. Discovery of the β₃-adrenoceptor with high expression in the bladder suggested that this receptor, which mediates detrusor relaxation, could be a target for overactive bladder symptoms., Materials and Methods: An overview of the published literature on β-adrenoceptor and the bladder was performed using MEDLINE. The United States Food and Drug Administration website, clinicaltrials.gov and controlled-trials.com online trial registries were searched for English language articles containing the terms β₃-adrenoceptors and β₃-adrenoceptor agonists. In addition, abstracts from recent international scientific meetings were searched for randomized, controlled trials of β₃-adrenoceptor agonists., Results: Stimulation of β₃-adrenoceptors relaxes detrusor smooth muscle, decreases afferent signaling from the bladder, improves bladder compliance upon filling and increases bladder capacity. Randomized, controlled trials show that the selective β₃-adrenoceptor agonist mirabegron, for which most information is available and which is approved in Japan, the United States and Europe, decreases the number of micturitions and incontinence episodes in a 24-hour period compared with placebo. The most common adverse effects recorded are dry mouth (placebo level) and gastrointestinal disturbances, rated as mild to moderate. Small increases in mean heart rate (1 beat per minute) and blood pressure (1 mm Hg) were noted in patients with overactive bladder., Conclusions: Available information suggests that β3-adrenoceptor agonists may be a promising alternative to antimuscarinics in the treatment of overactive bladder. However, further clinical experience outside clinical trials and information on long-term use in terms of efficacy, safety and tolerability are warranted to optimally characterize the position of β3-adrenoceptor agonists in the treatment algorithm for overactive bladder., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Objective methods are essential for evaluating post-prostatectomy incontinence. While symptom score and pad weight may be the most useful methods to evaluate preoperative vs postoperative continence, neither is useful for guiding intraoperative sling tension. The Virtue quadratic sling (Coloplast, Humlebaek, Denmark) is a new device for treating post-prostatectomy incontinence that combines a transobturator and prepubic surgical approach. We examined urethral resistance by measuring retrograde leak point pressure during key portions of the surgery., Materials and Methods: A total of 22 consecutive men who elected to undergo Virtue sling surgery were evaluated with retrograde leak point pressure before and during the surgery. Retrograde leak point pressure was measured via perfusion sphincterometry at baseline, after transobturator tensioning, after prepubic tensioning, and after transobturator and prepubic arms were secured in place., Results: Mean patient age was 70 years. Mean baseline retrograde leak point pressure was 33.4 ± 8.8 cm water. After transobturator tensioning, mean retrograde leak point pressure increased to 43.3 ± 6.8 cm water. After prepubic tensioning mean retrograde leak point pressure was 55.8 ± 8.7, and final retrograde leak point pressure after transobturator and prepubic fixation increased to 68.8 ± 6.0 cm water. Each mean retrograde leak point pressure value was significantly higher than the preceding value., Conclusions: The Virtue sling provides ventral urethral elevation using a transobturator approach, and a long segment of urethral compression against the genitourinary diaphragm via a straightforward prepubic technique without the risks of bone screws or retropubic needle passage. Transobturator and prepubic components of the quadratic fixation contributed to increasing urethral resistance as measured by intraoperative retrograde leak point pressure. This quadratic technique has a potentially greater ability to provide urethral compression than does a purely perineal or transobturator sling., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: More than 20 million Americans have an overactive bladder, the predominant symptoms being frequency, urgency, urge incontinence and pelvic pain. While the etiology is not completely understood, most investigators believe the causes to be many and the pelvic floor to be intimately related. Whatever the etiology, traditional therapies, including dietary manipulation, bladder drill, medications and physical therapy, are often poorly tolerated and/or ineffective. We report a prospective, multicenter clinical trial that was undertaken to determine the safety and efficacy of percutaneous peripheral afferent nerve stimulation for treatment of refractive overactive bladder and/or pelvic floor dysfunction., Materials and Methods: A total of 53 patients with overactive bladders, in whom all traditional therapy failed, were enrolled in 1 of 5 sites within the United States. Patients received weekly percutaneous electrical stimulations via a 34 gauge needle placed near the tibial nerve 3 finger breadths above the ankle. Urodynamic studies, detailed voiding diaries, quality of life surveys, and incontinence impact questionnaires were completed before, during and after the study., Results: Of the patients with a mean age of 57.4 years 89% (47 of 53) completed the 12-week study. A total of 71% of patients were classified as treatment successes by the investigators and were started on long-term treatment. On average patients noticed a 25% reduction in mean daytime and 21% reduction in mean nighttime voiding frequencies (p <0.05). Urge incontinence was reduced by an average of 35% (p <0.05). Statistically significant improvements were noted in selective pain and quality of life indexes. No significant adverse events related to treatment were noted in any patients., Conclusions: Percutaneous peripheral afferent nerve stimulation offers a safe, minimally invasive and effective treatment for managing refractive overactive bladder and/or pelvic floor dysfunction.

Purpose: We characterized presenting symptoms and urodynamic findings in women with dysfunctional voiding., Materials and Methods: We reviewed the charts of 26 women diagnosed with dysfunctional voiding. Those with a known or suspected history of neurological disease before evaluation were excluded from study. All patients completed an American Urological Association symptom index, and scores were classified as total, storage (irritative) and emptying (obstructive). The diagnosis of dysfunctional voiding was made on multichannel video urodynamics. There was increased external sphincter activity during voiding. Presenting symptoms and urodynamic findings in all cases were summarized. In addition, symptoms and urodynamic findings in patients later diagnosed with occult neurological disease were compared with those in patients without neurological disease., Results: Mean patient age was 39.2 years (range 19 to 79). Mean total American Urological Association-7 score was 24.4 of 35. Frequency and urgency were the most common presenting symptoms in 82% of cases. Mean storage score was 11.3 of 15 and mean voiding score was 13.2 of 20. Urge and stress incontinence was noted in 6 (23%) and 4 patients (15%), respectively, while 11 (42%) had a history of recurrent urinary tract infection. Cystometrography revealed detrusor instability in 11 cases (42%), sensory urgency in 11 (42%) and impaired compliance in 2 (8%), including 1 with instability. There was great variability in voiding parameters. Mean maximum urinary flow plus or minus standard deviation was 10.4 +/- 6.2 cc per second, mean detrusor pressure at maximum urinary flow was 50.3 +/- 23.5 cm. water and mean post-void residual urine volume was 103.4 +/- 120.0 cc. Video urodynamics prompted neurological evaluation, which revealed occult neurological disease in 5 patients who were then reclassified with external-detrusor sphincter dyssynergia., Conclusions: Female patients presenting with lower urinary tract symptoms may have dysfunctional voiding patterns. Storage symptoms appear to be even more common than voiding symptoms in this study group. These patients tend to have decreased flow, increased voiding pressure and high post-void residual urine volume. However, there is wide variation in these parameters among individuals. Therefore, careful review of the voiding phase, including pelvic floor electromyography and the fluoroscopic appearance of the bladder outlet, is critical. Occult neurological disease should be suspected in patients with dysfunctional voiding.

Purpose: Lower urinary tract symptoms in women are often evaluated by cystometrography. We only assessed the bladder response to filling and not the impact of abnormal voiding, which is known to cause lower urinary tract symptoms. We determined the prevalence of voiding abnormalities in women with lower urinary tract symptoms and compared cystometrography to cystometrography plus voiding pressure flow study for evaluating this condition. We also determined whether storage or voiding symptoms predicted abnormal voiding., Materials and Methods: We reviewed the records of 134 women who underwent video urodynamics with cystometrography and voiding pressure flow study to evaluate lower urinary tract symptoms. Patients with a history of neurological disease, grade 4 pelvic prolapse or a primary complaint of stress incontinence were excluded from study. All participants completed an American Urological Association symptom index and scores were subclassified as total, storage and voiding. A diagnosis was made in each case based on cystometrography findings, while any additional diagnoses when applicable were based on the voiding pressure flow study. Symptom scores were compared in women in whom the voiding study did and did not add information., Results: Mean patient age was 53.1 years (range 19 to 90). Voiding studies added information in 44 cases (33%), including dysfunctional voiding in 16, obstruction due to a moderate cystocele in 6, primary bladder neck obstruction in 6, external-detrusor sphincter dyssynergia as the initial presentation of neurological disease in 5, obstruction after incontinence surgery in 3, urethral stricture in 3, post-void contraction mimicking symptoms in 2, impaired contractility in 2 and an obstructing urethral diverticulum in 1. A total of 32 patients (24%) did not void during the study. Those with voiding abnormalities had higher total and voiding but similar storage symptom scores (23.1 versus 18.5, 12.3 versus 8.0 and 10.8 versus 10.5 points, p = 0.0008, 0.0001 and 0.58, respectively)., Conclusions: Women with lower urinary tract symptoms may have voiding abnormalities that are missed by cystometrography only. Voiding studies are useful for properly diagnosing and treating such cases. Women with abnormal voiding seem to have more severe voiding symptoms than those without such abnormalities. Occult neurological disease may also be identified in patients with lower urinary tract symptoms and voiding abnormalities.

Purpose: Various materials have been used for pubovaginal slings to correct female stress urinary incontinence. Use of synthetic materials provides a theoretical advantage in that no graft harvesting is necessary. Major risks of synthetic material use are erosion and infection of the sling. We report on erosion of woven polyester slings treated with pressure injected bovine collagen (ProteGen) which required removal., Materials and Methods: Office records of patients who had ProteGen slings removed at 5 centers during the last 24 months were retrospectively reviewed. Presenting symptoms, interval between sling placement and removal, subsequent procedures and continence status following sling removal were evaluated., Results: A total of 34 women required removal of the polyester sling secondary to erosion, infection or pain. The most common presenting complaints were delayed vaginal discharge in 21 patients (62%), vaginal pain or pressure in 21 (62%), suprapubic pain in 11 (32%) and recurrent urinary tract infection in 5 (15%) at a mean of 7.95 months (range 1 to 22) after sling placement. Of the patients 17 (50%) had vaginal erosion only, 7 (20%) isolated urethral erosion and 6 (17%) urethrovaginal fistulas. In 4 patients no erosion was obvious but slings were removed secondary to vaginal pain. Before sling removal 16 patients (47%) were totally dry, 13 (38%) had some degree of urinary incontinence and 3 (8%) had retention. Following sling removal 7 patients (20%) remained dry, 25 (74%) had mild to severe stress urinary incontinence with or without urgency and urge incontinence, and 2 (6%) are pending followup., Conclusions: Woven polyester slings treated with pressure injected bovine collagen are prone to erosion. Although the ProteGen sling was recalled in January 1999, patients who have had the sling placed must be followed closely.

Purpose: There are no universally accepted urodynamic criteria for diagnosing female bladder outlet obstruction. When accepted criteria for men are applied to women, the diagnosis of obstruction may often be missed, which is most likely due to differences in voiding dynamics. We propose video urodynamic criteria for diagnosing obstruction in women, and describe the urodynamic findings in those with and without obstruction., Materials and Methods: We reviewed the charts of 331 women who underwent multichannel video urodynamics for nonneurogenic voiding dysfunction. Of these women 261 (mean age 55.8 years) had evaluable voiding pressure flow studies with simultaneous video fluoroscopy of the bladder outlet during voiding. At video urodynamics cases were classified as obstructed if there was radiographic evidence of obstruction between the bladder neck and distal urethra in the presence of a sustained detrusor contraction. Strict pressure flow criteria were not used. Maximum flow rate, detrusor pressure at maximum flow rate, post-void residual, bladder capacity and the incidence of detrusor instability were compared between obstructed and unobstructed cases., Results: A total of 76 women met the criteria for obstruction (mean age 57.5 years), while 184 (mean age 55) did not. Causes of obstruction were dysfunctional voiding in 25 cases, cystocele in 21, primary bladder neck obstruction in 12, iatrogenic from incontinence surgery in 11, urethral stricture in 3, uterine prolapse in 2, urethral diverticulum in 1 and rectocele in 1. Obstructed cases had lower mean maximum flow rate (9 versus 20.2 ml. per second, p <0.0001), higher mean detrusor pressure at maximum flow rate (42.8 versus 22.1 cm. water, p <0.0001) and higher mean post-void residual (157 versus 33 ml., p <0.0001). There was no difference in bladder capacity (381 versus 347 ml.) or incidence of detrusor instability (45 versus 41%)., Conclusions: Using the proposed video urodynamic criteria obstructed cases had significantly higher voiding pressures, lower flow rates and higher post-void residual than unobstructed cases, as expected. However, absolute values, especially for voiding pressure, are not as dramatic in women as in men. Pressure flow studies alone may fail to diagnose obstruction but simultaneous imaging of the bladder outlet during voiding greatly facilitates diagnosis.

Purpose: We evaluated men with post-radical prostatectomy incontinence to determine the incidence of intrinsic sphincter deficiency and bladder dysfunction, and the contribution of each to incontinence. In addition, we determined if subjective symptoms of stress urinary incontinence and urge incontinence correlated with urodynamic findings of intrinsic sphincter deficiency and bladder dysfunction, respectively., Materials and Methods: A total of 60 consecutive patients (mean age 64.8 years) were prospectively evaluated with multichannel video urodynamics. All patients were evaluated at least 6 months postoperatively and had achieved a stable level of continence. Patients characterized incontinence as stress or urge related, and stress urinary incontinence was graded from 0 to 3. Intrinsic sphincter deficiency was defined as incontinence associated with increased intraabdominal pressure and was further assessed by Valsalva's leak point pressure. Bladder dysfunction included urodynamic findings of detrusor instability or decreased compliance., Results: Intrinsic sphincter deficiency was demonstrated in 54 patients (90%). Some component of bladder dysfunction was seen in 27 patients (45%), including detrusor instability in 24 and decreased compliance in 3, but incontinence was actually a result of bladder dysfunction in only 16 (27%). Incontinence was due to intrinsic sphincter deficiency alone in 40 patients (67%), intrinsic sphincter deficiency and bladder dysfunction in 14 (23%), and bladder dysfunction alone in only 2 (3%). Incontinence was not demonstrated on video urodynamics in 4 patients (7%). Of the 57 men who complained of stress urinary incontinence 54 demonstrated intrinsic sphincter deficiency for a positive predictive value of 95%. The 3 patients without stress urinary incontinence did not demonstrate intrinsic sphincter deficiency for a negative predictive value of 100%. Positive and negative predictive values for urge incontinence were 44 and 81%, respectively., Conclusions: Incontinence after radical prostatectomy is associated with intrinsic sphincter deficiency in the overwhelming majority of patients. Bladder dysfunction rarely is an isolated cause. When present on urodynamic tests bladder dysfunction may not always be a significant contributor to incontinence. The symptom of stress urinary incontinence (or its absence) accurately predicts the finding (or absence) of intrinsic sphincter deficiency on urodynamics. Urge incontinence is not as reliable in predicting incontinence due to bladder dysfunction.

Purpose: Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation., Materials and Methods: After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization., Results: Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2., Conclusions: Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

Purpose: There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys., Materials and Methods: We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux., Results: Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful., Conclusions: Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Purpose: We assessed the efficacy and safety of periurethral collagen injection for urinary incontinence in children with neurogenic bladder dysfunction., Materials and Methods: We treated 11 children (mean age 10.6 years) who had incontinence and neurogenic bladder dysfunction with periurethral injections of glutaraldehyde cross-linked collagen. All patients were on anticholinergics and all but 1 were on clean intermittent catheterization preoperatively. Four patients had previously undergone augmentation cystoplasty. All patients were assessed before and after injection with a subjective continence scale and multichannel urodynamics. Followup ranged from 4 to 20 months from the last injection., Results: Mean group Valsalva leak point pressure was 34.5 cm. water. Four of the 11 patients had an identifiable detrusor leak point pressure. Overall success rate was 55% with 4 patients dry and 2 improved. Success correlated with a minimum increase in Valsalva leak point pressure of 20 to 25 cm. water to greater than 60 cm. water. Three patients had no demonstrable Valsalva leak point pressure after injection. All 5 patients in whom treatment failed had no change in Valsalva leak point pressure, including 2 with small capacity, poorly compliant bladders preoperatively. Because they had a component of sphincteric insufficiency, they underwent injection in the hope of increasing capacity with increased continence. In 3 patients Valsalva leak point pressure was greater than 50 cm. water. Detrusor leak point pressure developed in 3 patients postoperatively, including 1 with significantly increased Valsalva leak point pressure. One patient with significantly increased Valsalva leak point pressure had urethral hypermobility postoperatively. Of the 3 patients who subsequently underwent augmentation cystoplasty 1 is now dry, 1 is wet and 1 died of complications unrelated to urological disease. Patients underwent 1 to 4 procedures (mean 2.5)., Conclusions: Periurethral collagen injection may be effective for urinary incontinence in patients who have adequate capacity with good compliance and low Valsalva leak point pressure. When there is no response to repeat injections or a transient response, one should consider the possibility of bladder decompensation.

Purpose: Persistent voiding dysfunction following transurethral resection of the prostate is not uncommon. We determined the correlation, if any, between the subjective complaints in men with voiding dysfunction after transurethral resection of the prostate and the urodynamic findings., Materials and Methods: A total of 50 consecutive men with voiding dysfunction following transurethral resection of the prostate was evaluated with the American Urological Association symptom index and multichannel urodynamics. Patients with urethral stricture, urinary retention or prostate cancer were excluded from the study. Urodynamic parameters assessed included detrusor instability, bladder capacity, sphincteric insufficiency using the Valsalva leak point pressure, voiding pressure-flow studies as determined by the Abrams-Griffiths nomogram (obstructed, unobstructed or equivocal) and post-void residual., Results: Mean patient age was 71 years and mean interval from last transurethral resection of the prostate was 58 months (range 2 to 252). Mean total, obstructive and irritative symptom scores were 16.3, 5.8 and 10.5, respectively. A total of 20 patients (40%) complained of incontinence (14 urge and 6 stress). According to the Abrams-Griffiths nomogram 62% of the cases were unobstructed, 16% obstructed and 22% equivocal. Urodynamic abnormalities were demonstrated in 43 patients (86%), and included detrusor instability (54%), obstruction with or without detrusor instability (16%), sphincteric insufficiency (8%), detrusor hypocontractility (4%) and sensory urgency (4%). There was no difference in the total, irritative or obstructive scores among obstructed, unobstructed or equivocal cases. Similarly there was no difference in scores among patients with and without detrusor instability. Age, number of transurethral resections and interval since last transurethral resection were unrelated to pressure-flow results or detrusor instability. Post-void residual was significantly greater in obstructed cases and bladder capacity was significantly less in those with detrusor instability. The cause of incontinence was demonstrated in 19 of 20 patients (95%): 4 (20%) had sphincteric insufficiency and 15 (75%) had detrusor instability., Conclusions: Symptoms are unreliable in predicting urodynamic findings with respect to obstruction and detrusor instability. There is a high incidence of detrusor instability in patients with voiding dysfunction after transurethral resection of the prostate. Urodynamic obstruction is a less likely occurrence.

Purpose: There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy., Materials and Methods: Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation., Results: Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months., Conclusions: Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

Purpose: We analyzed practice and referral patterns of primary care practitioners regarding the diagnosis of prostate cancer, and the evaluation and treatment of voiding dysfunction., Materials and Methods: An anonymous multiple-choice questionnaire was mailed to all primary care practitioners in Brooklyn, New York who were registered with the Medical Society of the State of New York., Results: More than 25% of primary care practitioners begin performing digital rectal examination after patient age 55 years. Compared to prostate specific antigen (PSA) 59% of practitioners believe that digital rectal examination is more sensitive or that the tests are equal, or they do not know. In regard to PSA 11% of respondents begin testing after patient age 60 years, 11% evaluate PSA only if digital rectal examination is abnormal and greater than 3% never evaluate PSA. Approximately 45% of primary care practitioners indicated that PSA of greater than 4.0 ng./ml. signifies prostate cancer regardless of patient age, prostate size or prostatis and 50% think that digital rectal examination elevates PSA in a clinically significant way. Although 93.2% of respondents refer a patient to a urologist after palpating a prostatic nodule, only 51.1% refer for an area of induration. Of the 47.2% of respondents who attempt pharmacotherapy for voiding dysfunction with finasteride, terazosin or both 15% do not know the agent mechanisms of action. Of those prescribing finasteride 68.6% are not aware of its effects on serum PSA. Overall 66.5% of primary care practitioners are not familiar with the American Urological Association Symptom Index while only 15% of those attempting pharmacotherapy use the index as a diagnostic tool., Conclusions: Primary care practitioners might require further education in regard to the use of PSA, digital rectal examination and pharmacotherapy in voiding dysfunction. Consideration should be given to the establishment of guidelines for urological referral.

Purpose: We correlated symptoms of stress urinary incontinence in women with intrinsic urethral function, as measured by Valsalva leak point pressure. In addition, we assessed the effects of urethral hypermobility, baseline resting abdominal pressure, patient age and menopausal status on Valsalva leak point pressure., Materials and Methods: We evaluated 64 consecutive women (mean age 50 years, range 20 to 79) with complaints of stress urinary incontinence. Initially the patient history was obtained and the subjective degree of stress urinary incontinence was graded as 1, 2 or 3 according to the SEAPI-QMN classification. Multichannel video urodynamics were then performed. At a volume of 150 to 200 ml. (or half bladder capacity when functional capacity was less than 150 ml.) filling was stopped. Resting, coughing and progressive Valsalva maneuvers were performed to determine Valsalva leak point pressure and the presence of urethral hypermobility. Valsalva leak point pressure was defined as the minimum total vesical pressure required to cause urinary incontinence in the absence of a detrusor contraction. Urodynamics were completed and detrusor instability or stress induced instability was noted., Results: Of the 64 women 52 (81.3%) had stress urinary incontinence. The exact test for trend demonstrated a statistically significant difference in the number of patients with a Valsalva leak point pressure of 90 cm. water or less (p = 0.0002) and 60 cm. water or less (p = 0.0002) among the 3 symptom groups. There was no correlation between Valsalva leak point pressure and resting vesical (which equals abdominal) pressure, patient age or menopausal status, or urge incontinence or detrusor instability among the 3 groups., Conclusions: The subjective degree of stress urinary incontinence can predict intrinsic urethral function as measured by Valsalva leak point pressure. Higher grades of stress urinary incontinence have a higher likelihood of a low Valsalva leak point pressure. Many women with grade 2 or 3 stress urinary incontinence have a Valsalva leak point pressure of 90 cm. water or less despite urethral hypermobility and they may have a component of intrinsic urethral deficiency.

Purpose: The etiology of voiding dysfunction was determined in men after a cerebrovascular accident who were at risk for obstructive uropathy to evaluate whether the cause of voiding dysfunction could be predicted by the type (obstructive or irritative) or onset of symptoms., Materials and Methods: We evaluated 38 men with complaints of voiding dysfunction following a cerebrovascular accident. All patients were of the age when bladder outlet obstruction secondary to benign prostatic hyperplasia would otherwise be prevalent. After a comprehensive history and physical examination, all patients underwent multichannel urodynamic studies at a medium fill rate (20 to 50 ml. per minute). Findings were classified by the Abrams-Griffiths nomogram as obstruction, no obstruction or equivocal., Results: Mean patient age was 70 years (range 54 to 87). Patients were grouped according to the presenting voiding complaints (purely irritative in 42%, purely obstructive in 34% or mixed in 24%). In 34 patients (89%) the onset of symptoms paralleled the occurrence of the cerebrovascular accident. Detrusor hyperreflexia was noted in 82% of the patients. There was no statistically significant difference in the occurrence of detrusor hyperreflexia among the 3 symptom groups (Fisher's exact test). Pressure-flow analysis clearly showed obstruction in 24 patients (63%), no obstruction in 9 (24%) and equivocal results in 5 (13%) according to the nomogram. There was no statistically significant difference in the incidence of obstruction among the 3 symptom groups (Fisher's exact test)., Conclusions: Presenting symptoms did not predict the urodynamic findings of bladder outlet obstruction or detrusor hyperreflexia. The significant incidence of onset of symptoms after stroke suggests that the cerebrovascular accident induced voiding dysfunction in the face of preexisting bladder outlet obstruction may exacerbate the symptoms of the latter condition or vice versa.

Mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism are 2 forms of male pseudohermaphroditism that present with absent müllerian regression and ambiguous genitalia. We present a retrospective analysis of 10 patients with the diagnosis of either mixed gonadal dysgenesis or dysgenetic male pseudohermaphroditism encountered during a 16-year period at our institution. We assigned a female gender to 4 patients and a male gender to 3. Three patients were assigned a male gender before referral (2 for whom we would have preferred female assignment). All intra-abdominal gonads were removed except in 2 patients assigned a male gender who underwent bilateral orchiopexy. Patients underwent hypospadias repair or feminizing genitoplasty depending upon the gender assigned. Although female gender assignment is usually preferred, male assignment is a justifiable alternative in instances of extreme virilization and a descended testis. However, in these male assigned patients, consideration must be given to the role of periodic testicular biopsies. In light of tumor potential, all intra-abdominal gonads should be removed. When necessary, appropriate surgical genitoplasty should be performed at an early patient age.

We reviewed the charts of 41 patients who underwent transvaginal urethrolysis and resuspension of the bladder neck by the Raz technique for urethral obstruction with or without stress urinary incontinence following anti-incontinence surgery. We sought to evaluate the effectiveness of the procedure as well as to determine any factors that had an effect on the outcome of surgery. Patients were evaluated for obstruction and stress urinary incontinence by history, physical examination, video urodynamics (or multichannel urodynamics plus cystogram and voiding cystourethrography) and cystoscopy. All patients reported normal emptying before the procedure that caused obstruction. Several variables were evaluated for individual predictive values for outcome, including type of surgery causing obstruction, number of previous anti-incontinence procedures, urodynamic evidence of obstruction (high pressure, low flow), instability, concomitant stress urinary incontinence and total urinary retention, which were evaluated by the Fisher exact test, and the amount of post-void residual, bladder capacity, maximum detrusor pressure, maximum urinary flow and interval since surgery causing obstruction, which were evaluated by logistic regression analysis. Mean patient age was 59 years (range 26 to 86 years) and mean followup was 21 months. A total of 19 patients (46%) suffered from concurrent stress urinary incontinence, 23 (56%) had urodynamic evidence of obstruction (high pressure/low flow) and 6 (15%) had only radiographic or endoscopic evidence with a deviated or kinked urethra. Postoperatively, 29 patients (71%) voided normally without significant residuals. Eight patients (20%) remain on self-catheterization and 1 has persistent stress urinary incontinence. When individual variables were evaluated to determine the predictive values with respect to outcome of urethrolysis, only the preoperative post-void residual was statistically significant (the greater the post-void residual, the more likely was failure, p = 0.021). The presence or strength of the detrusor contraction preoperatively and pressure-flow analysis did not predict outcome. Of the patients with stress urinary incontinence 15 (79%) were cured and 3 (16%) were significantly improved with rare stress urinary incontinence not requiring protection. Overall, 33 patients (80%) had some benefit from surgery. Patients who emptied normally before and anti-incontinence procedure that causes obstruction or impaired emptying should not be excluded from urethrolysis based on low detrusor pressures or pressure-flow analysis alone. Simultaneous radiographic imaging and endoscopy may help to select certain patients with obstruction.

Even complex vesicovaginal fistulas may be repaired transvaginally. In difficult repairs adjunctive measures have been described to increase the success rate of surgery, including Martius flaps, labial flaps or gracilis muscle flap. We describe a new technique to repair difficult vesicovaginal fistulas via a transvaginal approach. A flap of peritoneum is developed and used to buttress the fistula repair. This repair was successful in 9 of 11 patients (82%). Complications occurred in only 1 patient who suffered a bladder diverticulum containing a stone. The major advantage of this technique is its simplicity and lack of an extravaginal harvesting incision. This repair is particularly well suited for complex, high lying vesicovaginal fistulas.

We reviewed the charts of 92 women 65 years old and older (mean age 72 years, range 65 to 87 years) who underwent the Raz bladder neck suspension between January 1984 and June 1990 for stress urinary incontinence. Mean followup was 17 months. Overall, a successful outcome (cure or rare stress urinary incontinence not requiring protection) was achieved in 81 patients (88%). The 2-sample Wilcoxon rank sum test showed that the only predictor of outcome was the subjective degree of preoperative stress urinary incontinence (mild, moderate or severe, p = 0.0148). When the results were stratified by degree of incontinence preoperatively 8 of 8 patients (100%) with mild, 62 of 67 (93%) with moderate and 11 of 17 (65%) with severe incontinence had a successful outcome. Prior hysterectomy, number and type of previous anti-incontinence procedures, and the presence of urgency, urgency incontinence or urodynamic instability were not statistically significant predictors of outcome. In addition, the degree of clinical instability preoperatively had no correlation with the degree of postoperative instability. Of 11 failures 10 occurred within 1 year postoperatively. Significant urgency incontinence was present preoperatively in 32% of the patients with postoperative resolution in 60%. De novo urgency and urgency incontinence occurred in 24% and 13% of the patients, respectively. There was no statistically significant difference in the outcome of surgery in patients 65 years old and older compared to 141 patients less than 65 years old with respect to success, cure of stress urinary incontinence, cure of significant urgency and urgency incontinence, and appearance of de novo instability. The Raz bladder neck suspension is a safe and efficacious treatment for stress incontinence in elderly women. Outcomes can be expected to be the same as in younger women.

The urologist actively involved in the treatment of female genitourinary disease must to be able to recognize and treat various forms of pelvic prolapse. Enterocele is commonly seen in conjunction with stress urinary incontinence and cystocele or it may result from surgery to correct these problems. Many techniques to correct enterocele have been developed, including transvaginal repairs as well as intra-abdominal procedures such as the Moschcowitz technique or colpofixation to the sacrum for enterocele with vault prolapse. Surgical management of enterocele must take into account several factors, including the presence of stress urinary incontinence, rectocele, vaginal vault prolapse, prior hysterectomy and the desire to maintain sexual activity. Based on these considerations we discuss our approach to the transvaginal repair of enterocele. In patients without vault prolapse a simple enterocele repair is performed. If vault prolapse is present, then the condition of the anterior vaginal wall is considered. In patients with a cystocele a vault suspension procedure is performed, which involves simultaneous suspension of the uterosacral-cardinal ligament complex and vaginal vault along with the bladder neck and bladder. There are 2 modifications of this technique depending on the degree of cystocele: the 4-corner vault suspension for grades 2 and 3 cystocele, and the vault suspension with grade 4 cystocele repair. Patients with vault prolapse and no cystocele undergo sacrospinous ligament fixation. In elderly patients who are not sexually active, especially if they are in poor medical condition, partial colpocleisis is considered. In these patients partial colpocleisis was not performed as a primary procedure but it was done later in 3 who failed an initial attempt at repair. All coexisting vaginal pathology is fixed at the time of enterocele repair. A total of 83 patients underwent enterocele repair according to this protocol and 81 were available for followup. Mean followup was 15 months (range 3 to 70). Overall a successful result (no recurrence) was achieved in 70 patients (86%). Success for individual procedures was 40 of 49 (82%) for simple repair, 24 of 25 (96%) for vault suspension and 6 of 7 (86%) for sacrospinous fixation. In all cases vault suspension or sacrospinous fixation was able to restore vaginal depth and axis with minimal or no vaginal shortening.

We reviewed the charts of 206 patients who underwent the Raz bladder neck suspension between January 1984 and June 1990 for stress urinary incontinence. Mean followup was 15 months. Overall, our results demonstrated a successful outcome (cure or rare stress urinary incontinence not requiring protection) in 186 of 206 patients (90.3%). Cox multivariant analysis showed that the only predictor of outcome was the degree of preoperative stress urinary incontinence (mild, moderate or severe, p less than 0.001). When the results were stratified by degree of incontinence preoperatively 20 of 21 patients (95%) with mild, 151 of 162 (93%) with moderate and 15 of 23 (65%) with severe incontinence had a successful outcome. No statistical correlation was found with patient age, number of prior operations, hysterectomy, urgency incontinence or menopause. For the patients who failed, the mean interval to recurrent stress urinary incontinence was 5 months. Significant urgency incontinence was present preoperatively in 58 of the 204 patients (29%), with postoperative resolution in 66%. De novo urgency incontinence occurred in 7.5%. Complications included secondary prolapse (6% of the patients), prolonged retention (2.5%) and suprapubic pain (3%). In summary, the Raz bladder neck suspension for correction of stress urinary incontinence has been successful in more than 90% of this patient population.