Urinary Retention

Increased expression of heat shock protein 20 and decreased contractile stress in obstructed rat bladder.
Batts TW, Klausner AP, Jin Z, Meeks MK, Ripley ML, Yang SK, Tuttle JB, Steers WD, Rembold CM
J Urol. 2006 Oct;176(4):1679-84.

PURPOSE: Bladder outlet obstruction induces detrusor hypertrophy and it can eventually lead to decreased bladder smooth muscle contractility. Heat shock protein 20 is the proposed mediator of force suppression in vascular smooth muscle. We investigated whether heat shock protein 20 could also mediate the decreased contractility observed in partially obstructed rat bladders. MATERIALS AND METHODS: Female Wistar rats (Harlan Laboratories, Indianapolis, Indiana) were randomized to partial urethral ligation or sham ligation. After 3 weeks the rats were sacrificed, and the bladders were harvested, frozen, homogenized and analyzed for heat shock protein 20 content by Western blot immunoreactivity. The content of myosin regulatory light chain, a constitutively expressed protein, was determined as a control. Bladder smooth muscle strips were dissected from some rats and mounted for force generation measurement. RESULTS: At cystectomy obstructed bladders were significantly heavier and had more residual urine compared to sham operated bladders. Heat shock protein 20 immunoreactivity was significantly increased a mean +/- 1 SEM of 1.9 +/- 0.3-fold in obstructed vs sham operated bladders. Control protein myosin regulatory light chain immunoreactivity did not significantly differ in obstructed and sham operated bladders. Maximal stress, that is force per cross-sectional area, was significantly decreased in obstructed vs sham operated bladders. Human bladder was found to express immunoreactive heat shock protein 20. CONCLUSIONS: We noted that partially obstructed rat bladders 1) express higher levels of heat shock protein 20 and 2) generate less stress than sham operated bladders. These data suggest the possibility that heat shock protein 20 over expression could at least partially mediate the decreased contractile activity observed with partial bladder outlet obstruction. The mechanism for increased heat shock protein 20 expression is unknown but it may involve increased mechanical stress or hypoxia from urethral obstruction. Human bladder expressed immunoreactive heat shock protein 20, suggesting that a similar mechanism could potentially occur in humans. If confirmed in humans, patients with clinical conditions that result in detrusor hypocontractility could potentially benefit from pharmacological interventions aimed at inhibiting heat shock protein 20.

A selective alpha1A-adrenoceptor antagonist inhibits detrusor overactivity in a rat model of benign prostatic hyperplasia.
Tatemichi S, Akiyama K, Kobayashi M, Yamazaki Y, Yokoyama O, Uruno T
J Urol. 2006 Sep;176(3):1236-41.

PURPOSE: Alpha(1)-adrenoceptor antagonists relax the obstructed prostatic urethra and suppress the irritative symptoms frequently observed in patients with benign prostatic hyperplasia. We investigated the effects of 3 alpha(1)-adrenoceptor antagonists on urodynamics in rats with hormone induced benign prostatic hyperplasia to determine which alpha(1)-adrenoceptor subtype selective antagonists would suppress irritative symptoms. MATERIALS AND METHODS: Rats were treated with testosterone and 17beta-estradiol by weekly intramuscular injections. After 4 weeks a pressure flow study was done and the effects of the alpha(1)-adrenoceptor antagonists KMD-3213 silodosin, tamsulosin and prazosin on urodynamics were compared. We especially investigated the involvement of the bladder and prostatic urethra to clarify the mechanism of detrusor overactivity expression. RESULTS: Hormone treatment induced benign prostatic hyperplasia and resulted in detrusor overactivity, as determined by cystometry. Baseline perfusion urethral pressure and the phenylephrine induced increase in it were significantly higher in rats with vs without benign prostatic hyperplasia. Cystometry in hormone treated female rats did not show detrusor overactivity. KMD-3213 decreased detrusor overactivity, similar to other alpha(1)-adrenoceptor antagonists. CONCLUSIONS: These results suggest that an excessive response to sympathetic nerve stimulation, which is mainly mediated via alpha(1A)-adrenoceptor, in the hypertrophied prostate gives rise to detrusor overactivity. Furthermore, the alpha(1A)-adrenoceptor selective antagonist KMD-3213 would be suitable for improving irritative symptoms in patients with benign prostatic hyperplasia.

In vivo hepatocyte growth factor gene transfer to bladder smooth muscle after bladder outlet obstruction in the rat: a morphometric analysis.
Ku JH, Kim Y, Moon KC, Kim YS, Kim MS, Kim HH, Paick JS
J Urol. 2006 Sep;176(3):1230-5.

PURPOSE: We determined whether hepatocyte growth factor gene transfer after partial bladder outlet obstruction would prove effective for decreasing transforming growth factor-beta expression and consequently decreasing collagen deposition in partially obstructed rat bladders. MATERIALS AND METHODS: Ten-week-old male Sprague-Dawley rats were divided into 3 groups of 10 each, including group 1--sham operation, group 2--bladder outlet obstruction for 4 weeks and group 3--hepatocyte growth factor gene transfer after bladder outlet obstruction. Two weeks after the onset of bladder outlet obstruction in group 3 hepatocyte growth factor-liposome complex (50 microg human hepatocyte growth factor cDNA) was injected into the smooth muscle of the rats. RESULTS: We noted no difference between groups 2 and 3 with regard to the ratio of bladder weight to body weight. The ratio in groups 2 and 3 was significantly higher than in group 1 (p = 0.043). The mean percent of collagen area +/- SE was 36.32% +/- 1.83%, 27.90% +/- 2.66% and 8.97% +/- 3.35% in groups 1 to 3, respectively (p <0.05). Relative hepatocyte growth factor and c-met mRNA and protein expression were higher in group 3 than in groups 1 and 2. However, the expression of transforming growth factor-beta1 mRNA and protein was higher in group 2 than in groups 1 and 3. CONCLUSIONS: These findings may imply a possible novel therapeutic strategy against bladder dysfunction arising in patients with bladder outlet obstruction.

Activation of the calcineurin pathway is associated with detrusor decompensation: a potential therapeutic target.
Clement MR, Delaney DP, Austin JC, Sliwoski J, Hii GC, Canning DA, DiSanto ME, Chacko SK, Zderic SA
J Urol. 2006 Sep;176(3):1225-9.

PURPOSE: We hypothesized that the calcineurin pathway mediated some of the complex remodeling process that allows a bladder subjected to partial outlet obstruction to adapt to its new workload. Atrial natriuretic factor mRNA expression served as a marker of calcineurin activation. MATERIALS AND METHODS: A total of 16 New Zealand White rabbits underwent surgical creation of partial outlet obstruction, followed by randomization to receive cyclosporin A (20 mg/kg intramuscularly twice daily) or no additional treatment for 14 days. Three animals underwent 2 weeks of partial bladder outlet obstruction followed by bladder biopsy and the reversal of obstruction. RESULTS: Atrial natriuretic factor expression was seen only in bladders with severe hypertrophy and it disappeared with the reversal of outlet obstruction. Cyclosporin A treatment resulted in a decrease in atrial natriuretic factor mRNA expression (p <0.05) and a marked shift in myosin heavy chain A-to-B ratios toward normal (p <0.01) and an increase in smooth muscle cross sectional area (p <0.05). Bladder mass decreased 40% but did not attain statistical significance (p = 0.08). CONCLUSIONS: The calcineurin pathway has a significant role in bladder wall hypertrophy following partial outlet obstruction. Bladder hypertrophy could not be fully prevented by cyclosporin A, suggesting that multiple signaling pathways are involved in this pathophysiology. The expression of myosin heavy chain AB isoforms is regulated in part by the calcineurin pathway.

Management of urethral strictures.
Mundy AR
Postgrad Med J. 2006 Aug;82(970):489-93.

Controlled clinical trials are unusual in surgery, rare in urology, and almost non-existent as far as the management of urethral stricture is concerned. What data there are come largely from so called "expert opinion" and the quality of this is variable. None the less, the number of so called experts, past and present, is comparatively small and in broad principle their views more or less coincide. Although this review is therefore inevitably biased, it is unlikely that expert opinion will take issue with most of the general points raised here.

Anticholinergic Drugs in Patients with Bladder Outlet Obstruction and Lower Urinary Tract Symptoms: Where do we Stand in 2006?
Irani J
Eur Urol. 2006 Jul 28;.

Results of Double-Blind Placebo-Controlled Crossover Study of Sildenafil Citrate (Viagra) in Women Suffering from Obstructed Voiding or Retention Associated with the Primary Disorder of Sphincter Relaxation (Fowler's Syndrome).
Datta SN, Kavia RB, Gonzales G, Fowler CJ
Eur Urol. 2006 Jun 21;.

OBJECTIVES: Women with the primary disorder of sphincter relaxation find voiding difficult. Studies have identified neuronal nitric oxide synthase in the female urethral sphincter, and nitric oxide donors have been shown to decrease sphincter pressures. The aim of our study was to determine if sildenafil could improve sphincter relaxation and thereby increase flow rates and improve bladder emptying. METHODS: Twenty women with complete (5), partial retention or obstructed voiding (15) with a maximum flow rate (Qmax) of less than 15ml/min with an elevated maximal urethral closure pressure (92 - age cmH(2)O) and sphincter volume (>1.6cm(3)) were included in the study. The study was a double-blind, randomised, placebo-control, crossover design, with patients taking sildenafil or placebo, and with measurement of flow rate and residual volume at baseline and after each treatment phase. Voiding diary, quality of life, and International Prostate Symptom Score (IPSS) data were also collected. RESULTS: No statistical significant difference was seen in any voiding parameters and diaries when sildenafil citrate was compared with placebo. There was a significant mean decrease in IPSS of 3.64 between baseline and the sildenafil phase (p=0.0083), but not when compared with placebo. In the subgroup of women with partial retention and obstructed voiding (15/20), there was a statistically significant increase in Qmax of 4.7ml/sec (p=0.025) between sildenafil and baseline; however this difference was not seen when compared with placebo. CONCLUSIONS: This is the first study looking at sildenafil in voiding dysfunction in women. Clinical improvements with sildenafil were not significant when compared with placebo. Sildenafil was not effective as a therapeutic pharmacologic agent in this group of patients.

Anticholinergic Drugs in Patients with Bladder Outlet Obstruction and Lower Urinary Tract Symptoms: A Systematic Review.
Novara G, Galfano A, Ficarra V, Artibani W
Eur Urol. 2006 Jul 31;.

OBJECTIVES: To review the available evidence concerning the use of anticholinergic drugs, alone or in combination with alpha-blockers, in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) and concomitant overactive bladder syndrome, to assess whether the currently available evidence suggests a role for antimuscarinic drugs in patients with BPH. METHODS: A systematic review of the literature was performed using Embase, MEDLINE, and Web of Science through a complex search strategy including "free text" and "MeSH" protocols. Moreover, the Cochrane database of systematic review was browsed for records regarding BPH and the abstract books of the American Urological Association, European Association of Urology, and International Continence Society annual meetings from 2000 to 2005 were hand-searched for studies concerning the topic of the review. RESULTS: From the literature search, we identified four randomised controlled trials (RCTs), two prospective case series, and a few congress abstracts. For methodologic issues, the best RCT was based on urodynamic data, but did not provide any clinical insight on the patients' symptoms. The other papers were affected by significant methodologic or clinical drawbacks. CONCLUSION: The available data may be considered promising in terms of safety and efficacy. The evidence of the limited number of RCTs available, considering their methodologic or clinical shortcomings, is not sufficient to support the clinical use of combination therapy with alpha-blockers and anticholinergic drugs in patients with associated storage and voiding symptoms. Well-designed, large, double-blind, placebo-controlled, long-term RCTs are needed to assess the long-term safety and efficacy of antimuscarinic drugs, alone or in combination with alpha-blockers, in this category of patients.

Urinary retention caused by topical glycopyrrolate for hyperhidrosis.
Madan V, Beck MH
Br J Dermatol. 2006 Sep;155(3):634-5.

Clinically overt postpartum urinary retention after vaginal delivery: a retrospective case-control study.
Teo R, Punter J, Abrams K, Mayne C, Tincello D
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 23;.

We set out to determine the incidence of symptomatic postpartum urinary retention (PUR) after vaginal delivery and to establish any associated risk factors. We carried out a retrospective case-control study of women having PUR after vaginal delivery from 2001 to 2005. Four controls, matched for date of delivery, were selected for each case in univariate and multivariate conditional logistic regression analyses. There were 15,757 deliveries and 30 cases of PUR (incidence 0.2%). Median duration of PUR was 19 days (range 3-85). Eighty percent were managed with intermittent self-catheterization. The use of regional analgesia increased the risk of PUR [odds ratio (OR) 6.33, 95% confidence interval (CI) 2.01-19.96], while ethnicity (Caucasian vs Asian) reduced the risk (OR 0.27, CI 0.08-0.85) (p<0.05). PUR is uncommon but carries significant morbidity. Epidural analgesia and Asian ethnic origin increase the risk. We recommend routine catheterization for up to 24 h after delivery after epidural analgesia.

Response to daily 10 mg alfuzosin predicts acute urinary retention and benign prostatic hyperplasia related surgery in men with lower urinary tract symptoms.
Emberton M, Lukacs B, Matzkin H, Alcaraz A, Elhilali M, Vallancien G
J Urol. 2006 Sep;176(3):1051-6.

PURPOSE: We analyzed the influence of treatment response on the risk of acute urinary retention and benign prostatic hyperplasia related surgery in 5,792 men complaining of lower urinary tract symptoms who were treated for 6 months with the selective alpha1-blocker alfuzosin at 10 mg once daily. MATERIALS AND METHODS: The influence of dynamic variables (International Prostate Symptom Score change and bother during treatment) and baseline variables (patient age, prior acute urinary retention managed conservatively, prostate specific antigen, International Prostate Symptom Score and bother severity) on the risk of acute urinary retention and benign prostatic hyperplasia related surgery was estimated using the Kaplan-Meier method and log rank test. The associated HR and 95% CI were calculated using Cox proportional hazard models. RESULTS: During alfuzosin treatment International Prostate Symptom Score improved by 3 or greater and greater than 6 points in 74.8% and 50.3% of men, respectively. In this unselected population, including 3.8% with prior unoperated acute urinary retention, the rate of acute urinary retention and benign prostatic hyperplasia related surgery events during treatment was low (0.5% and 1.1%, respectively). Men with stable or worsening International Prostate Symptom Score were at increased risk for acute urinary retention or surgery (HR 3.75, 95% CI 1.58 to 8.89, p = 0.003 and HR 4.71, 95% CI 2.69 to 8.24, p <0.001, respectively). Prior acute urinary retention was a strong predictor of acute urinary retention relapse and surgery (HR 10.35, 95% CI 4.29 to 26.08, p <0.001 and HR 3.57, 95% CI 1.59 to 7.98, p = 0.002, respectively). Bother score greater than 3 during treatment was the strongest predictor of surgery (HR 7.61, 95% CI 4.16 to 13.93, p <0.001). Prostate specific antigen had much less predictive value. CONCLUSIONS: This 6-month real life practice study shows that alfuzosin is associated with a low incidence of acute urinary retention and benign prostatic hyperplasia related surgery. It also suggests that responder status is the most important predictor of acute urinary retention and benign prostatic hyperplasia related surgery. Thus, first line treatment with alfuzosin may help select patients at risk for benign prostatic hyperplasia progression to optimize treatment.

Botulinum a toxin urethral sphincter injection in children with nonneurogenic neurogenic bladder.
Mokhless I, Gaafar S, Fouda K, Shafik M, Assem A
J Urol. 2006 Oct;176(4 Suppl):1767-70.

PURPOSE: We evaluated botulinum-A toxin (Botox(R)) injection into the urethral urinary sphincter in children with nonneurogenic neurogenic bladder to decrease urethral resistance and improve voiding. In these patients alpha-blocker medications had failed and injection was an alternative to unavailable biofeedback. MATERIALS AND METHODS: Prospective treatment was performed in 10 children 6 to 17 years old (mean age 8) with nonneurogenic neurogenic bladder using botulinum-A toxin (Botox(R)). Preoperatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. One patient had unilateral G3 reflux and 4 had bilateral G1 to G3 hydronephrosis. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU botulinum-A toxin were injected into the external sphincter at the 3, 6 and 9 o'clock positions. Followup was 6 to 15 months. Repeat injections every month were given according to the response with a maximum of 3 injections. RESULTS: Immediately after botulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Four patients with bilateral hydronephrosis and the patient with the refluxing unit showed regression. Postoperatively post-void residual urine decreased by 89%, detrusor leak point pressure decreased significantly by a mean +/- SD of 66 +/- 18 vs 37 +/- 4 cm H(2)O and uroflowmetry showed a marked increase in maximum urine flow of 2 +/- 2 vs 17.8 +/- 8 ml per second. Three injections were needed in 1 patient to attain the desired response. CONCLUSIONS: Urethral sphincter botulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.

Dorsal buccal mucosa graft urethroplasty for female urethral strictures.
Migliari R, Leone P, Berdondini E, De Angelis M, Barbagli G, Palminteri E
J Urol. 2006 Oct;176(4):1473-6.

PURPOSE: We describe the feasibility and complications of dorsal buccal mucosa graft urethroplasty in female patients with urethral stenosis. MATERIALS AND METHODS: From April 2005 to July 2005, 3 women 45 to 65 years old (average age 53.7) with urethral stricture disease underwent urethral reconstruction using a dorsal buccal mucosa graft. Stricture etiology was unknown in 1 patient, ischemic in 1 and iatrogenic in 1. Buccal mucosa graft length was 5 to 6 cm and width was 2 to 3 cm. The urethra was freed dorsally until the bladder neck and then opened on the roof. The buccal mucosa patch was sutured to the margins of the opened urethra and the new roof of the augmented urethra was quilted to the clitoris corpora. RESULTS: In all cases voiding urethrogram after catheter removal showed a good urethral shape with absent urinary leakage. No urinary incontinence was evident postoperatively. On urodynamic investigation all patients showed an unobstructed Blaivas-Groutz nomogram. Two patients complained about irritative voiding symptoms at catheter removal, which subsided completely and spontaneously after a week. CONCLUSIONS: The dorsal approach with buccal mucosa graft allowed us to reconstruct an adequate urethra in females, decreasing the risks of incontinence and fistula.

The effect of terazosin on functional bladder outlet obstruction in women: a pilot study.
Kessler TM, Studer UE, Burkhard FC
J Urol. 2006 Oct;176(4):1487-92.

PURPOSE: We assessed the effect of terazosin (Hytrin(R)) on functional bladder outlet obstruction in women. MATERIALS AND METHODS: Functional bladder outlet obstruction was defined as a maximum flow rate of less than 12 ml per second combined with a detrusor pressure at maximum flow rate of more than 20 cm H(2)O in pressure flow studies in the absence of neurological disorders or mechanical causes. In a prospective pilot study 15 women with functional bladder outlet obstruction were treated with terazosin. Terazosin was initiated at 1 mg daily and gradually increased to the maintenance dose of 5 mg daily during 2 weeks. Symptoms and urodynamic parameters were assessed before and 3 to 4 weeks after the initiation of alpha-blocker therapy. RESULTS: While on terazosin, voiding symptoms subjectively improved greater than 50% in 10 of the 15 women (p = 0.002). Median maximum urethral closure pressure at rest decreased significantly from 98 to 70 cm H(2)O (p = 0.001), median maximum detrusor pressure decreased from 45 to 35 cm H(2)O (p = 0.008), median detrusor pressure at maximum flow decreased from 34 to 27 ml per second and median post-void residual urine decreased from 120 to 40 ml (p = 0.006 and 0.002, respectively). There was a significant increase in the median maximum flow rate from 9 to 20 ml per second and in median voided volume from 300 to 340 ml (p = 0.0005 and 0.021, respectively). Storage symptoms, functional urethral length and maximum cystometric capacity did not change significantly with alpha-blocker therapy (p >0.05). Overall terazosin resulted in a significant improvement in symptoms and urodynamic parameters in 10 of the 15 women (67%). CONCLUSIONS: Terazosin had a significant symptomatic and urodynamic effect in two-thirds of our patients. These results suggest that terazosin may be an effective treatment option in women with voiding dysfunction due to functional bladder outlet obstruction.

Transurethral ethanol injection for prostatic obstruction: an excellent treatment strategy for persistent urinary retention.
Mutaguchi K, Matsubara A, Kajiwara M, Hanada M, Mizoguchi H, Ohara S, Yasumoto H, Usui T
Urology. 2006 Aug;68(2):307-11.

OBJECTIVES: To evaluate the efficacy of transurethral ethanol injection into the prostate (TUEIP) for patients with persistent urinary retention resulting from benign prostatic hyperplasia or advanced prostate cancer. METHODS: Twenty-one Japanese men (elderly or at high risk anesthesiologically) who had developed persistent urinary retention because of benign prostatic hyperplasia or advanced prostate cancer were treated with TUEIP from January 2001 to January 2005. Patient age and preoperative prostate volume was 64 to 92 years (median 84) and 24.1 to 125 cm3 (mean 57.6), respectively. Under sacral or lumbar anesthesia, 6 to 14 mL (mean 10.6) of dehydrated ethanol (mean ratio for prostate volume 22.7%) was injected into the prostate under endoscopic guidance, followed by placement of an indwelling catheter. RESULTS: Of the 16 patients with benign prostatic hyperplasia and 5 with advanced prostate cancer, 14 (87.5%) and 3 (60%), respectively, were able to void spontaneously after catheter removal. The catheter had been left in place for 7 to 37 days (mean 12.4) after surgery. No additional treatment was required during the 2 to 24 months (mean 16) of follow-up. The postoperative residual urine volume of these 17 patients was 20 to 150 mL (mean 60) and their mean prostate volume had decreased from 52.7 to 37.9 cm3 (28.1% reduction) at 6 months postoperatively (P <0.001). No major complication was experienced. CONCLUSIONS: In patients with persistent urinary retention due to prostatic obstruction without severe complications, TUEIP removes the need for catheterization and allows spontaneous voiding. TUEIP may be an alternative to transurethral resection of the prostate for high-risk or elderly patients who cannot tolerate surgery.

Postoperative Ureteral Obstruction After Subureteral Injection of Dextranomer/Hyaluronic Acid Copolymer.
Vandersteen DR, Routh JC, Kirsch AJ, Scherz HC, Ritchey ML, Shapiro E, Wolpert JJ, Pfefferle H, Reinberg Y
J Urol. 2006 Oct;176(4):1593-1595.

PURPOSE: Subureteral injection of dextranomer/hyaluronic acid copolymer is widely accepted for the treatment of primary vesicoureteral reflux. Few studies document the incidence of surgically relevant postoperative obstruction or the characteristics of patients at risk. MATERIALS AND METHODS: Four institutions had reported surgically relevant postoperative obstruction to representatives of Q-Med Scandinavia, the manufacturers of Deflux(R) (dextranomer/hyaluronic acid). All children undergoing dextranomer/hyaluronic acid injection at these institutions were evaluated in this study. Patients requiring postoperative stenting were retrospectively reviewed for pertinent history, volume injected, technique of injection, duration of symptoms before intervention, duration of intervention and final outcome. RESULTS: A total of 745 patients (1,155 ureters) underwent injection. Five patients (6 renal units, 7 ureters) required stenting for obstructive symptoms and hydronephrosis, of whom 4 immediately became symptomatic. All patients had been injected with up to 1 ml dextranomer/hyaluronic acid. Four patients (80%) had either a neurogenic bladder or dysfunctional voiding. All stents were placed and removed without complications, with complete resolution of symptoms in all patients. Length of stenting ranged from 2 to 6 weeks. No patient required open surgery. One of 2 patients undergoing postoperative voiding studies had development of recurrent vesicoureteral reflux. CONCLUSIONS: Dextranomer/hyaluronic acid injection is associated with a small risk of postoperative ureteral obstruction requiring endoscopic intervention, with an overall incidence of less than 0.7% of patients injected. Patients with voiding dysfunction or neurogenic bladder may be at increased risk. Intervention with temporary ureteral stenting is effective, technically simple and curative.

Voiding dysfunction following removal of eroded synthetic mid urethral slings.
Starkman JS, Wolter C, Gomelsky A, Scarpero HM, Dmochowski RR
J Urol. 2006 Sep;176(3):1040-4.

PURPOSE: Voiding dysfunction following genitourinary erosion of synthetic mid urethral slings is not clearly reported. We investigated the incidence of voiding dysfunction in patients following sling excision due to vaginal, urethral or intravesical mesh erosion. MATERIALS AND METHODS: Retrospective review identified 19 patients with genitourinary erosion of polypropylene mesh slings. Comprehensive urological evaluation was performed in all patients, and perioperative and postoperative data were analyzed. Voiding dysfunction was defined as refractory storage symptoms, emptying symptoms and pelvic pain. All subsequent medical and surgical interventions were recorded. RESULTS: In 19 patients a total of 11 vaginal, 7 intravesical and 5 urethral erosions occurred. Mean patient age was 52 years (range 32 to 69) and average followup was 8.4 months (range 3 to 34). Average time from symptom onset to sling removal was 10.1 months (range 1.5 to 38). Of the 19 patients 14 (74%) presented with multiple symptoms. Symptoms varied, including refractory pain, recurrent infections and bladder storage/emptying dysfunction. Urodynamic studies were abnormal preoperatively and postoperatively in 9 of 13 (69%) and 4 of 6 patients (67%), respectively. Following surgery lower urinary tract symptoms resolved completely in only 4 of the 19 patients (21%). Stress incontinence recurred in 8 of the 19 patients (42%). Five patients underwent simultaneous pubovaginal sling, of whom none had recurrent stress urinary incontinence. Only 9 patients (47%) considered themselves dry with no pads following surgery. Four patients required further surgery for refractory voiding symptoms. CONCLUSIONS: Voiding dysfunction is not an uncommon finding after sling excision in the setting of genitourinary erosion. It may cause additional patient morbidity.

July

[Comparative study of the acceptability of the SpeediCath Set and Actreen set catheterization sets in patients performing self-catheterization]
Leriche A, Charvier K, Bonniaud V, Peyrat L, N'guyen P, Soler JM, Chapuis A, Egon G
Prog Urol. 2006 Jun;16(3):347-51.

OBJECTIVE: To compare SpeediCath Set to Actreen Set in terms of performance, acceptability and safety, in patients performing self-catheterization. MATERIAL AND METHODS: Four questionnaires were completed during this multicentre, randomized, crossover study: initial, after having tested each of the two products and patient preference at the end of the study. RESULTS: Analysis was based on 29 men performing self-catheterization. The SpeediCath Set was found to be superior to the Actreen Set in terms of ease of introduction (p=0.0055), ease of emptying (p=0.0157), quality of lubricant (p<0.0001), urethral tolerance and possibility of catheterization in bed (p= 0.0157). The patients 'global assessment was clearly in favour of SpeediCath Set (70 +/- 2.3 versus 5.7 +/- 2.5; p=0.0156) and 65.5% of patients preferred to use SpeediCath Set in the future. CONCLUSION: SpeediCath Set facilitates catheterization and improves the urethral tolerance compared to Actreen Set, with a marked patient preference in favour of SpeediCath Set.

A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure.
Laurikainen E, Kiilholma P
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):111-9. Epub 2005 Aug 24.

The role of transvaginal release procedure (TRP) for the treatment of urinary retention after TVT operation in Finland by the end of the year 2002 was evaluated. Questionnaires regarding the TVTs and the TRPs were sent to 56 hospitals. A retrospective review of the records of 48 women undergoing the TRP was available for analysis. TVT was performed on 9040 patients under local (94%), spinal (4%) or general (2%) anesthesia. TRP was made under local (48%), light (48%) or spinal (4%) anesthesia. The number of TRPs was 50/9040 (0.6%) in the whole country. Forty-nine percent of the patients were completely cured of their retention and remained continent after TRP by subjective report and by stress test. The retention following a TVT did not resolve in four patients (12%) who underwent TRP. This nationwide analysis proved that half of the patients remained continent after TRP, which is in our opinion an important information for all proceduralists.

June

Acute urinary retention as a result of a bladder diverticulum.
Aslam F, Syed JA, Nadeem N, Hussain S
Int J Urol. 2006 May;13(5):628-30.

An 11-month-old infant presented with acute urinary retention. He had presented 3 months earlier with complaints of an enlarging abdominal mass that was initially diagnosed as a mesenteric cyst on ultrasonography. Voiding cystourethrogram revealed a large bladder diverticulum. Bladder diverticulum should be a differential diagnosis in children, especially male, presenting with urinary retention, fever and an abdominal mass.

Anastomotic fibrous ring as cause of stricture recurrence after bulbar onlay graft urethroplasty.
Barbagli G, Guazzoni G, Palminteri E, Lazzeri M
J Urol. 2006 Aug;176(2):614-9.

PURPOSE: We retrospectively reviewed patterns of failure after bulbar substitution urethroplasty. In particular we investigated the prevalence and location of anastomotic fibrous ring strictures occurring at the apical anastomoses between the graft and urethral plate after 3 types of onlay graft techniques. MATERIALS AND METHODS: We reviewed the records of 107 patients who underwent bulbar urethroplasty between 1994 and 2004. Mean patient age was 44 years. Patients with lichen sclerosus, failed hypospadias repair or urethroplasty and panurethral strictures were excluded. A total of 45 patients underwent dorsal onlay skin graft urethroplasty, 50 underwent buccal mucosa onlay graft urethroplasty and 12 underwent augmented end-to-end urethroplasty. The clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean followup was 74 months (range 12 to 130). RESULTS: Of 107 cases 85 (80%) were successful and 22 (20%) failed. Failure in 12 patients (11%) involved the whole grafted area and in 10 (9%) it involved the anastomotic site, which was distal and proximal in 5 each. Urethrography, urethral ultrasound and urethroscopy were fundamental for determining the difference between full-length and focal extension of re-stricture. Failures were treated with multistage urethroplasty in 12 cases, urethrotomy in 7 and 1-stage urethroplasty in 3. Of the patients 16 had a satisfactory final outcome and 6 underwent definitive perineal urinary diversion. CONCLUSIONS: The prevalence and location of anastomotic ring strictures after bulbar urethroplasty were uniformly distributed in after 3 surgical techniques using skin or buccal mucosa. Further studies are necessary to clarify the etiology of these fibrous ring strictures.

Dorsal graft urethroplasty for female urethral stricture.
Tsivian A, Sidi AA
J Urol. 2006 Aug;176(2):611-3.

PURPOSE: Urethral strictures in females are uncommon, and treatment options and outcome are not well-defined with scanty reports. We describe a new method of urethroplasty for the repair of female urethral stricture. MATERIALS AND METHODS: Three 60-year-old females, each with a history of recurrent urinary tract infections and obstructive voiding symptoms due to urethral stricture, underwent urethroplasty with a dorsal vaginal or buccal mucosal graft. The dorsal aspect of the distal urethra was dissected from the surrounding tissue through a suprameatal incision and the urethral wall was incised through the stricture at the 12 o'clock position. A 1.5 cm wide free graft was harvested from the vaginal wall or buccal mucosa in 1 case, and the mucosal surface was placed upon the urethral lumen and sutured with a running 5-zero polyglactin suture to the open urethra. Indwelling 18Fr urethral and 16Fr suprapubic catheters were left in place for 2 and 3 weeks, respectively. RESULTS: No additional treatment was required during the 1, 8 and 27 months of followup. All patients had normal micturition following catheter removal. CONCLUSIONS: Dorsal graft urethroplasty is feasible and effective for the correction of persistent female urethral stricture.

May

Reliability of an automatic ultrasound system in the post partum period in measuring urinary retention.
Van Os AF, Van der Linden PJ
Acta Obstet Gynecol Scand. 2006;85(5):604-7.

BACKGROUND: Urinary retention in the post partum period may lead to short- and long-term complications. OBJECTIVE: To investigate the reliability of an automatic ultrasound system to measure the volume of the bladder post partum. METHODS: About 85 women, who delivered vaginally were observed 6 hr post partum. When the bladder volume measured by BladderScan BVI 3000 was more than 300 ml, it was compared with the bladder volume measured by catheterization. RESULTS: Ten additional catheterizations were performed by using BladderScan BVI 3000, when compared with the number of estimated cathetharizations based on clinical indications. Eight women had a residual volume of more than 300 ml, of whom two got an indwelling catheter. Using Bland-Altman methods, there was no significant difference in volumes measured by BladderScan BVI 3000 or by catheterization. Also, there was no significant difference between two observers. CONCLUSION: The BladderScan BVI 3000 is a reliable and non-invasive method to recognize urinary retention in the post partum period.

Lasers for the Treatment of Bladder Outlet Obstruction: Are They Challenging Conventional Treatment Modalities?
de la Rosette J, Alivizatos G
Eur Urol. 2006 May 2;.

Incidence of primary and recurrent acute urinary retention between 1998 and 2003 in England.
Cathcart P, van der Meulen J, Armitage J, Emberton M
J Urol. 2006 Jul;176(1):200-4.

PURPOSE: We report how the incidence of primary and recurrent acute urinary retention changed in England between 1998 and 2003. In addition, we present data on changes with time in the use of prostatectomy after acute urinary retention and recurrent acute urinary retention. MATERIALS AND METHODS: Data were extracted from the Hospital Episode Statistics database of the Department of Health in England. Patients were included in the study if an International Classification of Diseases, Tenth Revision code for acute urinary retention or an operative procedure code for transurethral prostate resection was present in any diagnosis or procedure fields of the Hospital Episode Statistics database. A total of 165,527 men were identified to have been hospitalized with acute urinary retention in the study period. RESULTS: The incidence of primary acute urinary retention was 3.06/1,000 men yearly. Acute urinary retention was spontaneous in 65.3% of cases. The incidence of acute urinary retention decreased from 3.17/1,000 men yearly in 1998 to 2.96/1,000 yearly in 2003. Surgical treatment following spontaneous acute urinary retention decreased 20% from 32% in 1998 to 26% in 2003. This trend coincided with a 20% increase in the rate of recurrent acute urinary retention. CONCLUSIONS: The slight decrease in the incidence of primary acute urinary retention suggests that the shift away from surgical treatment for benign prostatic hyperplasia has not resulted in an increase in acute urinary retention. The increase in recurrent acute urinary retention suggests that the observed decrease in surgery after acute urinary retention may have put more men at risk for acute urinary retention recurrence.

Effect of doxazosin with and without rho-kinase inhibitor on human corpus cavernosum smooth muscle in the presence of bladder outlet obstruction.
Demir O, Murat N, Aslan G, Gidener S, Esen AA
J Urol. 2006 Jun;175(6):2345-9.

PURPOSE: We investigated the relationship of adrenergic responses in corpus cavernosum tissues in the presence of BOO using the alpha1-adrenergic receptor antagonist doxazosin (Pfizer, New York, New York) and the rho-kinase inhibitor Y-27632 (Calbiochem, San Diego, California). MATERIALS AND METHODS: CCSM tissue was obtained from patients who underwent penile prosthesis implantation. Patients were divided into 2 groups according to the presence of BOO. The submaximal (EC80) concentration of phenylephrine (Sigma Chemical Co., St. Louis, Missouri) was calculated by evaluating adrenergic activity responses with cumulatively applied phenylephrine. After achieving a stable contraction plateau test compounds were put in an organ bath. The relaxant potencies of doxazosin and Y-27632 were expressed as the percent of inhibition of the contraction plateau induced EC80 concentration of phenylephrine. Relaxation responses in the 2 groups were compared. RESULTS: At the highest dose of increasing concentrations phenylephrine generated 70% more contraction response in the BOO positive group than in the BOO negative group. Doxazosin and Y-27632 caused concentration dependent relaxation in CCSM precontracted by phenylephrine. With doxazosin significantly higher relaxation responses were attained in the BOO positive group in terms of log IC50 and the maximal relaxation response (p = 0.0353 and 0.0003, respectively). Maximum relaxation responses following Y-27632 administration were significantly higher in the BOO positive group. CONCLUSIONS: The contractility of human corpus cavernosum is increased in the presence of BOO. Doxazosin and Y-27632 generate effective CCSM relaxation in the presence of BOO. Doxazosin and Y-27632 may be the alternatives for the treatment of erectile dysfunction associated with BPH.

Ultrasound assessment of detrusor thickness in men-can it predict bladder outlet obstruction and replace pressure flow study?
Kessler TM, Gerber R, Burkhard FC, Studer UE, Danuser H
J Urol. 2006 Jun;175(6):2170-3.

PURPOSE: We estimated the diagnostic accuracy of ultrasound detrusor thickness measurement for BOO and investigated whether this method can replace PFS for the diagnosis of BOO in some patients with lower urinary tract symptoms. MATERIALS AND METHODS: Detrusor thickness was measured by linear ultrasound (7.5 MHz) at a filling volume of greater than 50% of cystometric capacity in 102 men undergoing PFS for LUTS. All patients with prior treatment for bladder outlet obstruction and those with underlying neurological disorders were excluded from analysis. Detrusor thickness was correlated with PFS data. Obstruction was defined according to the Abrams-Griffiths nomogram. RESULTS: Detrusor thickness was significantly higher (p <0.0001) in obstructed (61 cases, median detrusor thickness 2.7 mm, IQR 2.4 to 3.3) compared to unobstructed (18 cases, median detrusor thickness 1.7 mm, IQR 1.5 to 2) as well as equivocal (23 cases, median detrusor thickness 1.8 mm, IQR 1.5 to 2.2) cases. A weak to medium Spearman correlation was found between detrusor thickness and PFS parameters. For a diagnosis of BOO, detrusor thickness of 2.9 mm or greater had a positive predictive value of 100%, a negative predictive value of 54%, specificity of 100% and sensitivity of 43%. ROC analysis revealed that detrusor thickness had a high predictive value for BOO with an AUC of 0.88 (95% CI 0.81-0.94). CONCLUSIONS: In men with LUTS without prior treatment and/or neurological disorders, ultrasonographically assessed detrusor thickness 2.9 mm or greater has a high predictive value for BOO and can replace PFS for the diagnosis of BOO. However, this cutoff value needs to be validated in a larger study population.

Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 2: noninvasive urodynamics and combination of measures.
Belal M, Abrams P
J Urol. 2006 Jul;176(1):29-35.

PURPOSE: Many methods have been suggested to diagnose bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison. MATERIALS AND METHODS: A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods, including single measure and combinations of measures, to diagnose bladder outlet obstruction. A direct comparison of all of the different methods was made using the sensitivity, specificity, likelihood ratio, and pretest and posttest probability of diagnosing bladder outlet obstruction for each test. For many techniques these values were calculated from the data presented in the article. RESULTS: A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods were considered in part 1 of the review. Part 2 considered noninvasive urodynamic techniques, such as uroflowmetry, the penile cuff, the condom method and Doppler urodynamics. A combination of single measures was also considered and the relative merits of these approaches were discussed. CONCLUSIONS: A combination of noninvasive urodynamics and ultrasound derived measures provide promising methods of diagnosing bladder outlet obstruction. However, pressure flow studies still remain the gold standard for assessing bladder outlet obstruction.

Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 1: nonurodynamic approach.
Belal M, Abrams P
J Urol. 2006 Jul;176(1):22-8.

PURPOSE: Many methods have been suggested for diagnosing bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature of the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison. MATERIALS AND METHODS: A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods used to diagnose bladder outlet obstruction. A direct comparison of all different methods was made using the sensitivity and specificity, positive predictive value and likelihood ratio of each test. For many of the techniques these values were calculated from the data presented in the article. RESULTS: A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods include symptoms, biochemical tests such as prostate specific antigen, ultrasound derived measurements such as post-void residual urine, bladder weight, prostate configuration and size, intravesical prostatic protrusion and the Doppler resistive index. Part 1 of the review explores and discusses the relative merits of the nonurodynamic based methods. CONCLUSIONS: Ultrasound derived measures such as bladder wall thickness and bladder weight offer a promising possibility of diagnosing bladder outlet obstruction noninvasively. However, further reproducibility and large accuracy studies with better methodological standards are required before they can replace pressure flow studies.

April

Acute urinary retention caused by a large peritoneal inclusion cyst: a case report.
Advincula AP, Hernandez JC
J Reprod Med. 2006 Mar;51(3):202-4.

BACKGROUND: Pelvic masses have been known to cause bladder symptoms and compression. This is the first documented case of a large peritoneal inclusion cyst causing acute urinary retention from bladder outlet obstruction. CASE: A 36-year-old woman, gravida 2, para 2, presented to the gynecology clinic with an indwelling Foley catheter that was placed at an outside hospital secondary to acute urinary retention. Computed tomography, performed several days earlier for complaints of progressively worsening lower abdominal and pelvic pain, revealed a 10-cm, complex, cystic mass within the pelvis between the rectum and sigmoid colon, with anterior displacement of the bladder. The patient's past surgical history included a total abdominal hysterectomy as well as separate exploratory laparotomy for resection of a 20-cm peritoneal inclusion cyst and a prophylactic bilateral salpingo-oophorectomy. Due to the acute urinary retention and worsening pain, the decision was made to proceed with laparoscopic removal and drainage of the mass, which turned out to be consistent with a recurrent peritoneal inclusion cyst. Symptom relief was immediate. CONCLUSION: A large, recurrent, peritoneal inclusion cyst obstructed the bladder neck and presented as acute urinary retention. Laparoscopy relieved the symptoms.

The prevalence of voiding difficulty after TVT, its impact on quality of life, and related risk factors.
Vervest HA, Bisseling TM, Heintz AP, Schraffordt Koops SE
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 22;.

Objective: To determine the prevalence of voiding difficulty (VD), quality of life, and related risk factors after tension-free vaginal tape (TVT). Design: Prospective cohort study in 703 women with a TVT procedure for stress urinary incontinence. Main outcome measures: VD stated by women, Urogenital Distress Inventory (UDI-6) question 5 (difficulty in emptying the bladder), maximum flow rate, postvoid residual urine, necessity of postoperative catheterization, tape division, and impact on quality of life (Incontinence Impact Questionnaire, IIQ-7). Results: Postoperative catheterization (>24 h) was necessary in 11% and tape division in 1.3% of patients. There were 26% of women who stated VD and 25% reported moderate to great impairment on the UDI-6 after 36 months. While the negative impact on the outcome of TVT in women with abnormal voiding compared to women without is higher, the impact decreased significantly after TVT, implying a considerable improvement in quality of life. Pre-operative existing voiding difficulty and concomitant prolapse surgery were independent risk factors. Conclusions: Symptoms of VD occurred after TVT and caused lesser improvement in quality of life.

Management of urethral strictures.
Waxman SW, Morey AF
Lancet. 2006 Apr 29;367(9520):1379-80.

Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls.
Wein AJ
J Urol. 2006 May;175(5):1802-3.

Diagnosis and treatment of primary bladder neck obstruction in men.
Wein AJ
J Urol. 2006 May;175(5):1802.

Prevention of chronic urinary retention in orthotopic bladder replacement in the female.
Smith JA Jr
J Urol. 2006 May;175(5):1766.

Postoperative voiding, bacteriuria and urinary tract infection with Foley catheterization after gynecological surgery.
Schiotz HA, Tanbo TG
Acta Obstet Gynecol Scand. 2006;85(4):476-81.

BACKGROUND: The use of bladder drainage to avoid urinary retention after gynecological surgery is more or less custom based, and duration of drainage varies considerably. In this paper the use of 1-day drainage by transurethral Foley catheter was investigated with regard to impaired voiding, asymptomatic bacteriuria, and urinary tract infection. Furthermore, the use of methenamine hippurate was studied with regard to postoperative asymptomatic bacteriuria and urinary tract infection. METHODS. This summary is based on six published papers totaling 917 patients. In three case series, 1-day catheterization was used in women undergoing gynecological laparotomy, colposuspension, or vaginal plastic surgery. To compare 1- and 3-day Foley catheterization, two open, randomized trials were performed on women undergoing vaginal plastic surgery or colposuspension. The last study was a double-blind trial between methenamine hippurate and placebo as prophylaxis against urinary tract infection and asymptomatic bacteriuria using 1-day catheterization. RESULTS: Postoperative voiding problems and urinary tract infection occurred infrequently with 1-day catheterization, and no more frequently than with catheterization for three days. Methenamine hippurate decreased the incidence of urinary tract infection and asymptomatic bacteriuria by 80 and 40%, respectively. CONCLUSIONS: One-day bladder drainage by transurethral Foley catheter may be used routinely in common gynecological surgery with a low rate of voiding problems, asymptomatic bacteriuria, and urinary tract infection. Methenamine hippurate prophylaxis effectively reduces postoperative urinary tract infection.

March

Does the MONARC transobturator suburethral sling cause post-operative voiding dysfunction? A prospective study.
Barry C, Naidu A, Lim Y, Corsitaans A, Muller R, Rane A
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):30-4. Epub 2005 Aug 11.

The aim of this study was to compare pre-operative and post-operative voiding parameters following insertion of the MONARC transobturator tape (TOT), for treating women with urodynamic stress incontinence. This prospective observational study was conducted at a tertiary referral urogynaecology unit, in North Queensland, involving 83 women who were prospectively assessed pre-operatively and at 6-8 weeks following the procedure. Information collected included patient demographics, concomitant surgery, pre-operative and post-operative symptomatology (using validated questionnaires), and pre-operative and post-operative urodynamic parameters. Parameters used to assess voiding function included symptoms of voiding difficulty (incomplete emptying and irritative symptoms) as well as objective parameters including maximum flow rate (Qmax), adjusted maximum flow rate (Qmaxadj) using the Liverpool nomogram (LN), maximal urethral pressure, and post-void residual (PVR). Pre-operative average Qmax was 23.7 ml/s compared to 21.1 ml/s post-operatively (p=0.064). When the Qmax was adjusted for voided volume using the LN, Qmaxadj was seen to decrease significantly from 26 ml/s to 18 ml/s (p<0.05). Women with PVR>50 ml did not differ significantly pre-operatively and post-operatively, 5/83(6%) vs 7/83 (8.4%) (p=0.75). The number of women with a flow rate <10th centile on LN was 22 (26.5%) pre-operatively vs 29 (34.9%) post-operatively (p=0.21). One (1.2%) post-operatively had voiding dysfunction diagnosed by an abnormal voiding pattern (p=0.728), which was not statistically significant. Objective voiding dysfunction as determined by adjusted flow rates <10th centile LN and >50 ml PVR was seen in four women (4.8%). Adjusted free flow rates are significantly reduced following insertion of the MONARC TOT, as are some symptoms related to voiding dysfunction. Despite this, satisfaction rates remain high with observed voiding dysfunction or objective measures of voiding dysfunction showing no statistical change in the short term. Long-term follow-up is planned at 1 year.

Dorsal buccal mucosal graft urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal approach for anterior urethral stricture.
Morey AF
J Urol. 2006 Apr;175(4):1395.

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach.
Morey AF
J Urol. 2006 Apr;175(4):1395.

Voiding dysfunction after abdominoplasty-an unusual complication.
Scheer I, Thakar R, Sultan AH, Newman-Saunders T
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 5;.

Abdominoplasty is an electively undertaken aesthetic operation mostly performed on patients after massive weight reduction. Previous case reports have demonstrated an improvement of incontinence symptoms after abdominoplasty. We report a case where urinary dysfunction occurred after refashioning of an abdominoplasty. The stress urinary incontinence got worse but what was of greater concern to her was a noticeable change of her urinary stream in an upward direction. A urethrolysis combined with an insertion of a tension-free vaginal tape and an anterior colporrhaphy was performed. After the operation, stress urinary incontinence improved and she reported that her urine stream reverted towards a normal direction.

Has the true prevalence of voiding difficulty in urogynecology patients been underestimated?
Haylen BT, Krishnan S, Schulz S, Verity L, Law M, Zhou J, Sutherst J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 5;.

Voiding difficulty has been relatively overlooked as a diagnosis. Previous estimates of its prevalence have generally been no more than 14% with one exception at 24%. The aim of this study is to determine the true prevalence and associations of voiding difficulty using a validated definition [urine flow rate under 10th centile of the Liverpool Nomograms and/or residual urine volume (by transvaginal ultrasound) more than 30 ml]. This study involved 592 women referred for an initial urogynecological assessment including urodynamics. Data were separated according to the presence or absence of voiding difficulty. The prevalence of voiding difficulty was 39%, far higher than previous estimates. It is the third most common urodynamic diagnosis behind urodynamic stress incontinence (USI-72%) and uterine/vaginal prolapse (61%) and ahead of the overactive bladder (13%). Voiding difficulty significantly increased in prevalence with age and increasing grades of all types of uterine/vaginal prolapse. Prolapse appeared to be the main factor in the age deterioration. Other significant positive relationships with voiding difficulty were prior hysterectomy and prior continence surgery, whilst USI and the symptom and sign of stress incontinence had significant inverse relationships.

Urethral stents for detrusor sphincter dyssynergia.
Morey AF
J Urol. 2006 Apr;175(4):1396.

[Treatment of bladder outlet obstruction secondary to suburethral tape by section of the tape]
Game X, Soulie M, Malavaud B, Seguin P, Vazzoler N, Sarramon JP, Plante P, Rischmann P
Prog Urol. 2006 Feb;16(1):67-71.

OBJECTIVES: To determine the results of treatment of chronic urinary retention secondary to bladder outlet obstruction complicating retropubic suburethral insertion of Tension-free Vaginal Tape (TVT) by section of this tape. MATERIAL AND METHODS: Between June 2000 and December 2004, 30 women with a mean age of 63.5 +/- 11.6 years underwent a single lateral urethral section of Tension-free Vaginal Tape to treat bladder outlet obstruction secondary to retropubic suburethral TVT insertion. Success was defined by resolution of the symptoms, a maximum urine flow rate greater than 15 ml/s and a post-voiding residual less than 50 ml and failure was defined by persistence of at least one of these three criteria. RESULTS: The mean interval between TVT placement and tape section was 12.7 +/- 14.7 months. The mean follow-up was 25.8 +/- 7.8 months. The cure rate was 70%. One complication (a bladder wound) was observed. Postoperatively, two patients (70%) developed recurrence of stress urinary incontinence. CONCLUSION: The treatment of chronic bladder outlet obstruction after retropubic TVT placement to treat stress urinary incontinence by single lateral urethral section of this tape is a simple and effective technique with low morbidity, accompanied by a very low urinary incontinence recurrence rate.

February

Healthy, middle-aged, history-free, continent women-do they strain to void?
Pauwels E, De Laet K, De Wachter S, Wyndaele JJ
J Urol. 2006 Apr;175(4):1403-7.

PURPOSE: We evaluated to what extent abdominal straining is used for voiding in an asymptomatic, continent, healthy, middle-aged female population. MATERIALS AND METHODS: A total of 32 women (mean age 49 +/- 6 years old) could be prospectively included. Technical investigations consisted of flowmetry, pressure flowmetry with EMG and electrosensation evaluation. Some data were compared with those of stress incontinent women investigated prospectively in the same way. RESULTS: There were 4 women who were excluded from analysis because of abnormal sensory evaluation. The symptom-free participants voided with low detrusor pressure, a high flow rate and no residual. A large segment (42%) used additional abdominal straining to void on cystometry and reported that such straining was their usual habit for voiding at home. Straining was seen as frequent in women with stress incontinence. However, significantly more women with stress incontinence used straining without detrusor contraction. CONCLUSIONS: These healthy middle-aged women without a history of pelvic surgery, or symptoms or signs of urological, anorectal or gynecological problems, voided with a mean Pdetmax of 25 cm H(2)O, mean Qmax of 29 ml per second, and the majority without residual. Many of them strained during detrusor contraction and this had not led to the development of signs or symptoms. The way straining is done may make the difference in that during reflex bladder contraction and urethral relaxation, additional straining may have little negative effect. If straining is used to void without the initiation of the micturition reflex, voiding dysfunction and incontinence might develop more easily.

Technique and results of urethroplasty for female stricture disease.
Schwender CE, Ng L, McGuire E, Gormley EA
J Urol. 2006 Mar;175(3 Pt 1):976-80; discussion 980.

PURPOSE: Urethral stricture disease in females is uncommon and is often treated with repeat dilation or internal urethrotomies. Various surgical techniques to repair strictures have been described with successful results. However, these techniques are cumbersome to use. The vaginal inlay flap is simple and easy to learn. To our knowledge this is the first report of its use and clinical results in a series of patients from 2 institutions. MATERIALS AND METHODS: Eight symptomatic women with a history of traumatic or difficult catheterization, a history of at least 1 urethral dilation or urethrotomy and difficult or a failed attempt at catheter placement underwent urethroplasty. The technique consisted of incising the posterior aspect of the stricture and advancing a vaginal inlay flap. A retrospective chart review was performed. RESULTS: Followup was 1 to 9 years. All patients had subjective relief of symptoms and could easily catheterize with a 14Fr catheter. Average caliber of the urethra increased from 9.25Fr to 16.5Fr and post-void residual urine decreased from 130 to 15 cc. One patient with a hypotonic bladder was in retention, which resolved during 3 months. One patient underwent repeat dilation once 3 weeks after the primary procedure with no recurrence. No patient had stress urinary incontinence. There were no immediate or delayed serious complications. CONCLUSIONS: Urethral stricture disease in females is an uncommon entity that can cause voiding symptoms, recurrent infections, retention and renal impairment. This method of surgical repair offers a durable result and has a low incidence of complications.

Herpes zoster-associated acute urinary retention: a case report.
Julia JJ, Cholhan HJ
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 7;.

An 87-year-old woman presents with a 4-week history of urinary incontinence during which she had been treated for disseminated herpes zoster virus (HZV). On physical exam painful vesicles involving the entire vulvar region with mainly right sacral distribution were found. A catheterized volume exceeded 600 ml of retained urine after the patient failed to void spontaneously. Multichannel voiding-pressure urodynamic studies revealed an acontractile neurogenic bladder with overflow incontinence. The patient was discharged on a conservative regimen with arrangement for visiting nurse services to perform intermittent self-catheterization twice daily. Urodynamic testing was repeated 10 weeks after initial symptoms. During voiding cystometry a biphasic increase in detrusor pressure of 15 cm H(2)O was observed with no increase in abdominal pressure. The patient emptied 400 ml with a postvoid residual of 300 ml. Recovery from HZV-associated bladder emptying dysfunction can be achieved usually through conservative management, including intermittent self-catheterization. Complete recovery time ranges from 4 to 10 weeks.

Obstructive primary bladder neck disease: evaluation of the efficacy and safety of alpha1-blockers.
Cisternino A, Zeccolini G, Calpista A, De Marco V, Prayer Galetti T, Iafrate M, Artibani W
Urol Int. 2006;76(2):150-3.

OBJECTIVE: The efficacy and safety of using alpha(1)-adrenergic blockers for treating primary bladder neck obstruction in young and middle-aged men was assessed as the first therapeutic step, before surgery, in a symptomatic non-neurogenic selected group of patients. MATERIALS AND METHODS: From January 1995 to December 2001, primary bladder neck obstruction was diagnosed in 41 men whose average age was 43 years. All of them were evaluated by a complete clinical history, American Urological Association (AUA) symptom score index, physical examination, uroflowmetry, transabdominal ultrasound prostatic volume determination, ultrasound post-void residual determination, videourodynamics including pressure-flow analysis and upper urinary tract screening with renal ultrasound or an excretory urogram. A full daily dose of alpha(1)-adrenergic blockers (alfuzosin or tamsulosin) was administered for at least 6 months. Successful treatment was defined as improved symptoms, voiding diary, maximum flow rate and pressure-flow parameters. Patients who did not gain improvement of symptoms with pharmacological treatment were offered surgery. RESULTS: Overall, pharmacological treatment was successful in 29/41 patients (70.7%) whereas bladder neck endoscopic incision was mandatory in 12/41 (29.3%). CONCLUSIONS: alpha(1)-Blockers were effective and safe for treating young and middle-aged men with symptomatic bladder neck obstruction.

Technique and results of urethroplasty for female stricture disease.
Schwender CE, Ng L, McGuire E, Gormley EA
J Urol. 2006 Mar;175(3 Pt 1):976-80; discussion 980.

PURPOSE: Urethral stricture disease in females is uncommon and is often treated with repeat dilation or internal urethrotomies. Various surgical techniques to repair strictures have been described with successful results. However, these techniques are cumbersome to use. The vaginal inlay flap is simple and easy to learn. To our knowledge this is the first report of its use and clinical results in a series of patients from 2 institutions. MATERIALS AND METHODS: Eight symptomatic women with a history of traumatic or difficult catheterization, a history of at least 1 urethral dilation or urethrotomy and difficult or a failed attempt at catheter placement underwent urethroplasty. The technique consisted of incising the posterior aspect of the stricture and advancing a vaginal inlay flap. A retrospective chart review was performed. RESULTS: Followup was 1 to 9 years. All patients had subjective relief of symptoms and could easily catheterize with a 14Fr catheter. Average caliber of the urethra increased from 9.25Fr to 16.5Fr and post-void residual urine decreased from 130 to 15 cc. One patient with a hypotonic bladder was in retention, which resolved during 3 months. One patient underwent repeat dilation once 3 weeks after the primary procedure with no recurrence. No patient had stress urinary incontinence. There were no immediate or delayed serious complications. CONCLUSIONS: Urethral stricture disease in females is an uncommon entity that can cause voiding symptoms, recurrent infections, retention and renal impairment. This method of surgical repair offers a durable result and has a low incidence of complications.

January

Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery.
Segal J, Steele A, Vassallo B, Kleeman S, Silva AW, Pauls R, Walsh P, Karram M
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 21;:1-6.

OBJECTIVE: The aims of this study are to report the efficacy of retropubic urethrolysis, vaginal urethrolysis, and cutting of synthetic suburethral slings in treating postoperative voiding dysfunction that occurs after anti-incontinence surgery and to report the recurrence rate of stress urinary incontinence (SUI). METHODS: All patients from January 1996 to October 2003 who presented with voiding dysfunction following an anti-incontinence procedure and who subsequently underwent either retropubic urethrolysis, vaginal urethrolysis, or synthetic suburethral sling takedown were included in the study. Pre- and postoperative irritative symptoms (urinary frequency or urgency), obstructive symptoms (hesitancy, voiding difficulty, and incomplete emptying), and stress urinary incontinence symptoms were obtained in a standardized fashion. The Incontinence Impact Questionnaire and Urogenital Distres Invetory quality of life (QOL) questionnaires were also obtained to objectify these symptoms. Other objective postoperative analysis included simple uroflowmetry, measurement of postvoid residual (PVR), and simple or subtracted cystometry. RESULTS: Forty-four patients were included in the study (suburethral sling takedown=14, vaginal urethrolysis=20, and retropubic urethrolysis=10), 77% of whom had objective follow-up. Preoperatively, 31 patients (70.5%) had irritative symptoms, 41 (93.2%) had obstructive symptoms, and 6 (13.6%) had symptoms of stress urinary incontinence (SUI), while postoperatively, these symptoms were found in 30 (68.2%), 11 (25.0%), and 18 (40.9%), respectively. Postoperatively, 6 patients (17.6%) had a PVR> 100 cc, 5 patients (14.7%) had a bladder contractions, and 16 patients (47.1%) demonstrated the sign or diagnosis of (SUI). Additionally, there was a statistically significant improvement in both QOL questionnaires. CONCLUSIONS: Various surgical approaches may be used to treat voiding dysfunction following an anti-incontinence procedure. Following a vaginal or retropubic urethrolysis or takedown of a synthetic suburethral sling, obstructive symptoms are likely to improve, irritative symptoms may remain unchanged, and almost half will develop recurrence of SUI.

Urinary retention following tension-free vaginal tape successfully treated by sacral neuromodulation.
Adam RA
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 12;:1-2.

Postoperative urinary retention following anti-incontinence surgery has traditionally been thought to be due to overcorrection. There is increasing evidence, however, that a neurogenic component may also play a significant role. This is a case report of a 72-year-old woman who developed delayed partial urinary retention following a tension-free vaginal tape which resolved with initial sacral neuromodulation.

Two cases of female acute urinary retention caused by an impacted pelvic mass.
Hosokawa Y, Kishino T, Ono T, Oyama N, Momose H
Int J Urol. 2005 Dec;12(12):1069-70.

We report two cases of acute urinary retention in women with an impacted pelvic mass. In both cases, all urinary symptoms resolved completely after the surgical removal of the mass.

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