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D S Blander

Publications and source records attributed to D S Blander.

13 recordsLinked to original sources
PubMed2001

New millennium, new slings.

The etiology of stress incontinence is not completely understood. In the past, bladder neck suspensions were performed to correct anatomic abnormalities of the bladder neck and urethral hypermobility. This procedure was attractive because of its simplicity, low morbidity, and excellent early success rate. With time, the successes seen with bladder neck suspensions have not proven to be durable, and alternative surgical procedures have been developed. Until recently, the indications for bladder neck suspension were types I and II stress incontinence; slings were reserved for type III incontinence. However, slings have been shown to be as effective as and more durable than bladder neck suspensions for treatment of all types of stress incontinence; therefore, their popularity has spread. The success of distal urethral slings suggests that it is not necessary to correct anatomic hypermobility to correct stress incontinence. A plethora of new procedures and materials has emerged, leading to an increased need for well-controlled, objective outcome studies in order to understand the impact of these surgeries on our patients.

Biocompatible Materials↗
PubMed2001

Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women.

OBJECTIVES: Accurate determination of the size and extent of urethral diverticula can be important in planning operative reconstruction and repair. Voiding cystourethrography (VCUG) is currently the most commonly used study in the preoperative evaluation of urethral diverticula. We reviewed our experience with the use of endoluminal (endorectal or endovaginal) magnetic resonance imaging (eMRI) in these patients as an adjunctive study to VCUG to evaluate whether the MRI provided anatomically important information that was not apparent on VCUG. METHODS: A retrospective analysis of all patients with a clinical diagnosis of urethral diverticula undergoing MRI at a single institution was performed. Patients were evaluated with history, physical examination, cystoscopy, VCUG, and eMRI. Endoluminal MRI was retrospectively compared to VCUG with respect to size, extent, and location found at operative exploration. RESULTS: Twenty-seven consecutive patients underwent endorectal or endovaginal coil MRI in the evaluation of suspected urethral diverticula. Twenty patients subsequently had attempted transvaginal operative repair of the diverticulum. In 2 patients, eMRI demonstrated a urethral diverticulum, whereas VCUG did not. Operative exploration in these patients revealed a urethral diverticulum. In 14 of 27 patients, the VCUG underestimated the size and complexity of the urethral diverticulum as compared to eMRI and operative exploration. In 13 of 27 patients, the size, location, and extent of the urethral diverticulum on VCUG correlated well with the eMRI and/or operative findings. CONCLUSIONS: We have found endorectal and endovaginal coil MRI to be extremely accurate in determining the size and extent of urethral diverticula as compared to VCUG. This information can be critical when planning the approach, dissection, and reconstruction of these sometimes complex cases.

Adult↗
PubMed2001

Vaginal vault fixation and prevention of enterocele recurrence by high midline levator myorraphy: physical examination and questionnaire-based follow-up.

OBJECTIVES: To assess outcome following a vaginal repair (high midline levator myorraphy, HMLM) for vaginal vault prolapse. METHODS: Women were identified who had undergone HMLM between December 1995 and September 1998. A structured telephone interview consisting of 5 questions was conducted in all those who could be reached. The most recent results of physical examination, based on office records, were also collected. RESULTS: Thirty-five of 47 women completed the interview (average age 71 years, mean time since surgery, 27.9 months). Five patients had developed recurrent prolapse requiring repair (anterior enterocele in 3, vault prolapse in 1, symptomatic cystocele in 1). Recurrent cystoceles were noted on examination in 7 women (5 grade 1, 2 grade 2). Overall, 17 women were extremely satisfied with the result (>90% satisfied); 6 were dissatisfied (<50%). Five women were noted to have transiently reduced unilateral ureteral drainage intraoperatively, and all cases were resolved after the removal or replacement of one of the levator myorraphy sutures. One patient required re-exploration for ureteral obstruction, which resolved after replacement of a suture and stenting. CONCLUSIONS: Levator myorraphy is safe, effective, and easily taught. The rate of recurrent prolapse associated with this technique is similar to other techniques for vaginal vault fixation, but it avoids the disadvantages of an abdominal approach and is more technically straightforward to perform than sacrospinalis fixation.

Aged↗
PubMed2000

The levator myorraphy repair for vaginal vault prolapse.

Various techniques have been described for the repair of vaginal vault prolapse after hysterectomy. Because of inherent difficulties associated with the sacrospinous fixation, a new repair, the levator myorraphy, was devised to simplify reconstruction of the pelvic floor 10 years ago. This repair results in a restored vaginal axis and prevention of posterior enterocele recurrence by recreating the levator shelf high within the peritoneal cavity and fixing the vault in that position. Because this procedure can be performed from a vaginal approach, morbidity is minimized. Over this 10-year time period, we have performed the levator myorraphy in over 120 women. We believe this approach can be easily taught, is highly effective, and results in a repair that most closely restores the normal anatomic position.

Female↗
PubMed2000

Cadaveric fascia lata sling: analysis of five recent adverse outcomes.

OBJECTIVES: To report a series of adverse outcomes of urethral sling procedures that used allograft fascia lata and to review the literature regarding the use of this material in genitourinary reconstruction. METHODS: Five neurologically normal patients presented to our center between August 1999 and October 1999 with complaints of recurrent incontinence or voiding dysfunction after undergoing urethral sling procedures at outside institutions that used fascia lata allografts. All patients underwent a thorough evaluation, including history and physical examination, voiding cystourethrography, and urodynamic studies. Sections of fascia were removed for histology in 2 patients at the time of operation. RESULTS: Three patients were diagnosed with de novo bladder outlet obstruction, 1 with recurrent urethral hypermobility, and 1 with intrinsic sphincteric deficiency. Histology of cadaveric fascia demonstrated collagen with almost complete absence of cellularity. There was no evidence of capillary or fibroblast ingrowth. All patients underwent reoperation and have had clinical improvement with short-term follow-up. CONCLUSIONS: Although distressing, the present series of adverse outcomes may simply reflect an overall increase in the number of sling procedures being performed nationally. Although decreased operative time and morbidity have been attributed to the use of fascia lata in urethral sling procedures, it is essential to ensure that long-term safety and efficacy will not be jeopardized before accepting it as a new standard of care.

Adult↗
PubMed2000

Transvaginal repair of postcystectomy peritoneovaginal fistulae.

To our knowledge, peritoneovaginal fistula is a complication of cystectomy that has not been reported before. We describe 2 patients in whom a transvaginal approach using a Martius flap was utilized to repair persistent vaginal leakage after cystectomy. At a mean follow-up of 20 months, both patients are free from vaginal leakage and have no evidence of recurrent fistula. This approach offers a safe and effective way to repair a peritoneovaginal fistula in a cystectomy patient.

Cystectomy↗
PubMed2000

Efficacy of sildenafil in erectile dysfunction after radical prostatectomy.

Radical retropubic prostatectomy (RRP) is an important cause of iatrogenic erectile dysfunction (ED). While sildenafil has been widely used since its introduction as a new treatment option for ED, its efficacy in post-RRP patients has not been extensively studied. We retrospectively compared the efficacy of sildenafil in post-RRP and non-surgical patients with ED (NSED) using a subset of questions from the International Index of Erectile Function (IIEF) and correlated results with their specific etiology of ED based on penile blood flow study (PBFS). A brief questionnaire regarding satisfaction with sildenafil was administered to 72 consecutive post-RRP patients (nerve sparing status unknown) and 32 consecutive NSED patients who had previously undergone PBFS with pharmacotesting as part of their evaluation for ED. PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) < 25 cm/sec; venogenic (CVOD) for PSV > or = 35 cm/sec, mixed vascular for PV > 25 but < 35 cm/sec and resistive index (RI) < 0.9; a vascular normal diagnosis (neurogenic impotence) required excellent rigidity sustained for 20 min. Differences in the IIEF subscores for the different groups of patients were assessed. Success with sildenafil was defined as moderate or excellent improvement (3/4 or 4/4) with ability for penetration. No differences were found among the different subgroups of RRP patients with respect to IIEF scores or success rates with sildenafil. NSED patients had both significantly higher post-treatment IIEF scores (3.6/3.4 vs 2.5/2.2; t=4.50, P<0.0001) and success rates (63% vs 31%; t=3.11, P < 0.01) with sildenafil treatment than RRP patients. We found that sildenafil is significantly less effective in impotent RRP patients than in age-matched patients with ED (31% vs 63%). We had postulated that sildenafil would be least effective among RRP patients with excellent sustained rigidity to PGE1, as this subgroup is likely to have neurogenic impotence. We found that sildenafil response rates among subgroups of RRP patients were statistically similar regardless of PBFS diagnosis. IIEF scores for the RRP subgroups were similar but statistically lower than in men with ED and no history of RRP. While individuals with normal vascular responses to PGE1 have an increased likelihood of having neurogenic impotence, in RRP patients, we were unable to demonstrate any difference in efficacy of sildenafil, regardless of the PBFS diagnosis.

Aged↗
PubMed1999

Extraperitoneal laparoscopic urethropexy with Marlex mesh.

OBJECTIVES: Extraperitoneal laparoscopic urethropexy (ELU) has recently been developed as a minimally invasive procedure for the treatment of female stress urinary incontinence (SUI). Use of the laparoscopic stapling device and Marlex mesh in the extraperitoneal space may allow for a technically easier procedure and shorter operative times compared with other laparoscopic techniques without compromising long-term efficacy. We present our initial results and 2.5-year interim analysis with this alternative method of laparoscopic urethropexy. METHODS: Twenty-four consecutive patients with urodynamically demonstrated genuine SUI underwent attempted ELU at a single institution from December 1994 to December 1995. Operative data were collected from the patient chart, and follow-up data were obtained by telephone interview. Treatment was considered successful if, at last follow-up, a patient was using one or fewer pads daily and would recommend the procedure to a friend. RESULTS: ELU was completed in 22 of 24 patients. In 1 patient with a prior history of pelvic surgery, the preperitoneal space was not accessible. Of the 22 patients, 20 were available for follow-up. The mean operative time was 69 minutes. There were no intraoperative complications. At initial follow-up (mean 10.5 months), 18 (90%) of 20 patients reported subjective cure of SUI (one or fewer pads daily). At a mean follow-up of 29 months (range 23 to 34), 16 (80%) of 20 patients had subjective cure of SUI. Six patients would not recommend the procedure to a friend, all of whom had de novo urgency and/or urge incontinence. Thus, using our strict criteria, ELU was successful in 14 (70%) of 20 patients at a mean follow-up of 2.5 years. No patient has had permanent urinary retention. CONCLUSIONS: ELU can be performed rapidly and safely in patients without previous pelvic surgery. De novo urgency incontinence may be problematic. Future analysis of this subset of patients will determine whether this procedure is durable in the long term.

Adult↗
PubMed1999

Sex inventories: can questionnaires replace erectile dysfunction testing?

OBJECTIVES: "Paper and pencil" sexual inventories are widely used by the pharmaceutical industry for categorizing the severity of erectile dysfunction (ED) and for efficacy end points of drug therapy. The International Index of Erectile Function (IIEF) evaluates several domains of male sexual behavior: erection, orgasm, desire, and satisfaction. We compared the subjective IIEF score for erectile function with the severity and etiology of ED as determined by pharmacologic testing with prostaglandin E1 (PGE1) and color duplex Doppler ultrasound testing (penile blood flow study [PBFS]). METHODS: Five questions from the IIEF that require the patient to quantify his erectile performance were compared with PBFS data. Examiners were unaware of IIEF scores during testing. PBFSs were performed after PGE1 injection, privacy, and self-stimulation; dosing was 6 microg (50 to 59 years) or 10 microg (60 years or older). PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) less than 25 cm/s; cavernous venous occlusive disease (CVOD) for PSV greater than 35 cm/s and resistive index (RI) less than 0.9; and mixed vascular erectile dysfunction for a PSV from 25 to 35 cm/s and RI less than 0.9. A normal vascular diagnosis required a PSV greater than 35 cm/s and an RI of 0.9 or greater. Visual ratings of the erectile responses without Doppler assessment (inadequate, adequate, or excellent) were also compared with the IIEF and Viagra Study Group criteria (Q3+4). RESULTS: Eighty-nine patients underwent the complete evaluation. Eight patients (9%) were found to be normal vascularly (mean PSV 40.9 cm/s, mean RI 0.99). Thirty-four patients (38%) had AI (mean PSV 17.5, mean RI 0.74), 33 patients (37%) had mixed vascular ED (mean PSV 29.1, mean RI 0.80), and 14 patients (16%) had CVOD (mean PSV 45.9, mean RI 0.73). The mean IIEF score for the normal responders was 13.3; patients with AI, mixed vascular ED, and CVOD had mean IIEF scores of 6.9, 8.5, and 8.1, respectively. IIEF and Q3+4 values differed significantly between the normal and abnormal groups (P<0.05 and P<0.025, respectively), but no statistically significant differences in IIEF or Q3+4 scores were noted among the subgroups of abnormal responders. Analysis of the visual ratings of erections demonstrated that IIEF scores were significantly different between inadequate and excellent responders (P<0.05). CONCLUSIONS: IIEF scores did not statistically differentiate among the specific etiologies of ED as determined by evidence-based testing with PBFS. Furthermore, patients with normal results after testing with PGE1 (10 microg or less) had surprisingly low self-ratings of erectile performance (13 of 25 points). For the primary caregiver, the IIEF may help in the taking of the male sexual history, but for the specialist, sexual inventory scores will not distinguish among the various etiologies of vascular ED and do not predict the results of pharmacologic testing.

Erectile Dysfunction↗
PubMed1999

Retrospective review of flow patterns following retropubic prostatectomy.

AIM OF THIS STUDY: We retrospectively evaluated penile inflows in 103 previously potent individuals who underwent standard nerve sparing radical retropubic prostatectomy (RRP) for the treatment of prostate cancer. No effort to identify or spare the accessory pudendal artery (APA) was made in any case. Our goal was to investigate the role of the accessory internal pudendal artery (APA) in the maintenance of erections in this population. We hypothesize that if the APA is present in a significant number of men, and its ligation significantly contributes to post-RRP impotence, then there should be an increased incidence of asymmetry between R/L cavernous arterial flows among post RRP patients with vascular impotence. MATERIALS AND METHODS: One hundred and three previously potent individuals complaining of persistent erectile dysfunction for at least six months after RRP were studied with color duplex Doppler, following age specific dosing of PGE1. Vascular assessment was performed before and after self-stimulation, measuring peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI). Erections were visually rated as inadequate (INA), adequate (ADE) for penetration, or excellent (EXC) with sustained rigidity for at least 20 min. Cavernous artery asymmetry (CAA) was defined as a >10 cm/s difference between right and left sided arterial flows. RESULTS: Mean duration between surgery and Doppler study was 14.7 months. 27 out of 103 (26%) of patients developed excellent rigidity consistent with isolated neurogenic impotence (PSV=32.0 cm/s, mean RI=0.95); 24 out of 103 (23%) had adequate vascular responses making it impossible to infer presence or absences of neurogenic impotence; 52 out of 103 (51%) had inadequate rigidity consistent with vascular insufficiency (PSV=23.7 cm/s, mean RI=0.66). We noted that of patients with EXC response, 48% (13 out of 27) had CAA. Among patients with severe inflow disease (INA responders), CAA was seen in only 21% of cases (11 out of 52). CONCLUSIONS: The incidence of APA has been reported as being from 4-70%, and its significance in the maintenance of erections has been questioned. Assuming that the APA provides significant inflow in some patients, we expected an increase in CAA in individuals in whom it was sacrificed. We found a higher incidence of CAA among post-RRP patients with normal vascular erectile responses to PGE1 (48%) compared to men with true vasculogenic impotence post-RRP (21%). These data do not support the importance of the APA in the maintenance of erections in the post-RRP patient.

Aged↗
PubMed1997

Collagen injection therapy for post-radical retropubic prostatectomy incontinence: role of Valsalva leak point pressure.

PURPOSE: We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS: Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS: Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS: Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

Adult↗
PubMed1991

A conditioned stimulus decreases extracellular dopamine in the nucleus accumbens after the development of a learned taste aversion.

The conditioned taste aversion (CTA) paradigm and microdialysis were used to determine if extracellular dopamine in the nucleus accumbens is related to the reward value of a stimulus. Intraorally applied saccharin caused a 37% increase in DA in naive rats and a 40% decrease in subjects with a CTA to this taste. These results suggest that accumbens DA is not just a function of arousal but is related to stimulus reward.

Administration, Oral↗