Biomedical subjects
Publications and source records attributed to F Haab.
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The Martius pedicle adipose flap can be used as an interposition flap during complex vaginal operations. It is a simple, rapid technique allowing raising of a well vascularized adipose flap with a mean length of 8 to 12 cm. It can be used in certain forms of vaginal repair, such as high supratrigonal vesicovaginal fistula, after bladder perforation, for obstructed urethra after colposuspension, after urethral destruction following prolonged bladder catheterization in a neurological patient, during repair of a complex urethral diverticulum or during transvaginal insertion of an artificial sphincter. After describing the flap raising operative technique, the various operative indications are presented.
PURPOSE: We prospectively compared the efficacy of 2 bulking agents to treat incontinence related to intrinsic sphincter deficiency. MATERIALS AND METHODS: A total of 67 women underwent periurethral injection for intrinsic sphincter deficiency at the same institution performed by 1 surgeon. Patients were divided into 45 who received fat (group 1) and 22 who received collagen (group 2) injections. Both groups were comparable for age, parity, number of previously failed procedures and number of pads used daily. Preoperative urodynamic evaluation revealed a low Valsalva leak point pressure in both groups (mean plus or minus standard deviation 23.82 +/- 12.41 versus 29.35 +/- 11.32, not significant). Patients rated the subjective degree of postoperative improvement as 0 to 100%. RESULTS: At a mean followup of 7 months after the last injection only 13% of the fat group and 24% of the collagen group were cured. The mean percentage of subjective improvement was significantly greater in the collagen than in the fat group (70.9 +/- 28 versus 31.2 +/- 41.7%, respectively, p < 0.001). The failure rate was significantly greater in the fat group compared to the collagen group (p < 0.001). CONCLUSIONS: Based on results of a prospective comparison of fat and collagen injection, collagen is more effective than fat for treatment of intrinsic sphincter deficiency.
PURPOSE: We determined the long-term efficacy and quality of life impact of the artificial urinary sphincter. MATERIALS AND METHODS: We reviewed the medical records of 68 men who underwent artificial urinary sphincter placement for post-prostatectomy incontinence (64) or neurogenic disease (4) between March 1980 and March 1992 (mean followup 7.2 years). Quality of life was assessed in 52 patients who completed the incontinence impact questionnaire and the urogenital distress inventory. RESULTS: At followup 54 men were socially continent (0 or 1 pad per day). Overall, pad score decreased significantly from 2.75 before to 0.97 after artificial urinary sphincter implantation (p < 0.001). The artificial urinary sphincter was permanently removed in 4 patients. Revisions for mechanical failure or urethral atrophy were required in 25% of the patients (mean 1.35 procedures per patient). The mechanical failure rate decreased significantly after 1987 due to device improvements (12.4 versus 44.4%, p < 0.01). Subjective improvement and overall satisfaction were rated as 4.1 and 3.9, respectively (scale 0 to 5). At followup the mean values of the incontinence impact questionnaire and urogenital distress inventory demonstrated the positive impact of the artificial urinary sphincter on quality of life. CONCLUSIONS: This long-term study documents the positive impact of the artificial urinary sphincter on patient quality of life with few mechanical failures since 1987.
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OBJECTIVE: To determine the influence of the bladder filling volume on the Valsalva Leak Point Pressure (VLPP) in patients investigated for urinary stress incontinence. PATIENTS AND METHODS: 50 patients investigated for urinary stress incontinence were included in this prospective study. Evaluation consisted of clinical examination, urodynamic examination with simultaneous fluoroscopic assessment and cystoscopy. VLPP was measured while standing every 100 cc during filling until the cystomanometric bladder capacity. RESULTS: We observed a significant reduction of VLPP as a function of bladder filling volume. The VLPP measured at 200 cc constituted the reference value in view of its sensitivity and specificity for the diagnosis of type III urinary stress incontinence (Blaivas' classification). CONCLUSION: Measurement of VLPP must be standardized and interpreted as a function of bladder filling volume.
OBJECTIVE: Infravesical obstruction can occur after surgical cure for urinary stress incontinence (USI). Apart from palliative treatments with limited effects, this iatrogenic complication can be corrected by complete urethrolysis. The various indications and techniques of this surgery are presented. METHOD: Urethrolysis is designed to release the urethra and bladder neck and can be performed via a transvaginal or retropubic approach. Some authors then recommend resuspension of the bladder neck, while others use a Martius or omentum flap to reduce the risk of restenosis. RESULTS: The success of urethrolysis is measured by the return of normal micturition with complete disappearance of the irritating and/or obstructive symptoms. The success rate for the transvaginal procedure varies from 65% to 92% according to different teams, while the success rate via an abdominal incision was 93% in one series. CONCLUSION: Urethrolysis is a difficult surgical technique, whose long-term results have not yet been precisely determined. The transvaginal route is associated with a low morbidity and remains our personal preference to release the obstructed urethra after operation for USI.
PURPOSE: We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction. MATERIALS AND METHODS: A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases. RESULTS: Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30% of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision. CONCLUSIONS: Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.
PURPOSE: We examined urodynamic findings and treatment outcomes in a large population of men with post-prostatectomy incontinence. MATERIALS AND METHODS: A total of 215 men was referred for evaluation and treatment of significant post-prostatectomy incontinence. Urodynamic evaluation consisted of provocation multichannel medium fill cystometry with vigorous attempts to demonstrate incontinence. Treatment was directed by the results of the urodynamic study. A pad scoring system was used to gauge the severity of incontinence before and after treatment. RESULTS: Based on the results of urodynamic studies 40% of the men had genuine stress incontinence alone and approximately 60% had a major component of bladder dysfunction contributing to incontinence. Treatment results of 135 men demonstrated a significant decrease in pad score (p<0.001) for those treated with anticholinergics, those undergoing artificial sphincter insertion and those treated pharmacologically before sphincter placement. CONCLUSIONS: In our large series most men with prostatectomy incontinence did not have genuine stress incontinence alone. Thus, urodynamic studies are critical, not only to define cause of incontinence but to direct effective therapy.
Post-prostatectomy incontinence is a devastating complication that is frustrating for the patient and the surgeon. Bladder dysfunction with or without sphincteric incompetence is the main cause for post-prostatectomy incontinence. Treatment based on the urodynamic evaluation is effective in restoring continence and improving the patient's quality of life.
OBJECTIVE: To report an unusual and life-threatening presentation of a nonseminomatous germ cell tumor of the testis. METHODS: A 35-year-old male presented with pulmonary embolism secondary to a neoplastic thrombus from a nonseminomatous germ cell tumor. Prompt management involved surgical thrombectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest, followed by orchiectomy and adjuvant chemotherapy. RESULTS: Three years later, the patient remains disease free according to physical examination, radiographic workup and serum markers. CONCLUSION: The excellent long-term outcome of this patient supports an aggressive multidisciplinary management of nonseminomatous germ cell tumors in young adults.
PURPOSE: This study was designed to determine whether lowering the initial reperfusion pressure can improve renal function after ischemia. MATERIALS AND DESIGN: Sixty minutes of warm renal ischemia was induced in 2 groups of 8 minipigs by clamping the left renal artery. Right kidneys were kept in situ as controls. In the standard reperfusion group, ischemic kidneys were immediately reperfused at systemic pressure. In the controlled reperfusion group, the renal artery reperfusion pressure was maintained at 60 mm. Hg for the initial 20 minutes of reperfusion by use of a regulating pump and then at systemic pressure for the next 100 minutes. RESULTS: On the basis of the postischemic anuria rate, glomerular filtration rate and renal histology, renal tolerance to ischemia was significantly improved in the controlled reperfusion group. CONCLUSION: These findings of improved renal function recovery after warm ischemia by controlled low reperfusion pressure may have clinical relevance to the reperfusion technique used after renal transplantation in humans.
PURPOSE: The recent literature on intrinsic sphincteric deficiency is reviewed. MATERIALS AND METHODS: We performed an extensive literature search related to the diagnosis, management and treatment of intrinsic sphincteric deficiency. RESULTS: Stress urinary incontinence results from insufficient urethral resistance and/or support during increases in intra-abdominal pressure. Since treatment of stress urinary incontinence is closely related to the mechanism of urinary leakage, recognition of intrinsic sphincteric deficiency is of the utmost importance in its evaluation. Furthermore, to date there is no consensus on the treatment of intrinsic sphincteric deficiency and various procedures may be considered. CONCLUSIONS: The pathophysiology of urinary incontinence in female patients is still controversial. Intrinsic sphincteric deficiency is best recognized by history and clinical examination in conjunction with documentation of severe stress urinary incontinence, a fixed urethra and a low Valsalva leak point pressure. The pubo-vaginal sling procedure still represents the most widely accepted treatment to correct intrinsic sphincteric deficiency.
Recent progress in the techniques used to assay prostate specific antigen (PSA) have made this diagnostic tool even more useful in the management of patients with cancer of the prostate. However, although "ultrasensitive" methods can now detect minute levels, there still is no widely accepted definition of the detection threshold making it difficult to compare results reported with the different techniques. Ultrasensitive assay is particularly interesting in patients who have had radical prostatectomy, offering complementary information to the pathology examination of the surgical specimen. Used as a tool for following disease course after surgery, ultrasensitive PSA is currently the most sensitive measure of disease recurrence. Ultrasensitive assay can also give an evaluation of the effect of post-surgery complementary radiotherapy. Inversely, it adds no further information compared with regular assay before surgery. Thus, ultrasensitive assay is not indicated for differential diagnosis or screening programmes but is a valuable tool for evaluating the effectiveness of curative surgery or exclusive curative radiotherapy.
OBJECTIVE: To study the clearance of serum prostate-specific antigen (PSA) after several types of prostatic tissue ablation. METHODS: Serum PSA levels were measured (YANG Proscheck ultrasensitive assay) just before surgery, immediately after specimen removal, then twice weekly for 5 weeks or until it was undetectable (< 0.05 ng/ml) in patients undergoing radical cystoprostatectomy for bladder cancer (n = 10), or radical prostatectomy for T1 T2 prostate cancer (n = 18) and daily for 6 days after open surgery for benign prostatic hypertrophy (BPH) (n = 10). RESULTS: Open enucleation for BPH: the immediately postoperative PSA level was 6 times its preoperative value. It decreased following a monoexponential curve with a very short half-life of 0.55 +/- 0.39 days, range (0.14-1.3), reaching a value lower than the preoperative level in all cases, except one by day 3. After radical cystoprostatectomy: the decrease of serum PSA is monoexponential with a half life of 1.92 +/- 1.2 days (0.57-4.24) reaching undetectable level (< 0.05 ng/ml) in all patients by day 21. After radical prostatectomy: 11/18 patients (61%) showed a one-component exponential decrease in PSA with a half-life of 2.5 +/- 1.33 days (range 0.97-4.6 days), and 7/18 showed a two-component exponential decrease with a first half-life of 0.94 +/- 0.8 days and a second of 7.62 +/- 6.35 days); 100% of the patients reached undetectable serum PSA by day 28 in the first group compared to 14.2% of the patients with a two component exponential decrease (P < 0.01). There was no difference between these groups as far as preoperative PSA levels and specimen pathology were concerned. CONCLUSION: Serum clearance of PSA after extirpative prostatic surgery is closely related to the type and indication of procedure used. Radical cystoprostatectomy is probably the best model in which to study the pharmacokinetics of PSA.
During the last 15 years 8 patients were diagnosed with renin secreting juxtaglomerular cell tumors among 30,000 hypertensive patients. Clinical characteristics included severe hypertension poorly medically controlled in young patients (mean age 22.3 years) and severe hypokalemia (mean 2.83 mmol./l.). Secondary hyperaldosteronism was present in all cases with a constant elevation of renin activity. Renal vein sampling was only positive in 64% of cases. Selective renal arteriography demonstrated an avascular area in 43% of the patients. Computerized tomography showed the tumor in all cases. Mean tumor size was 24 mm. (range 10 to 50). Conservative surgery was feasible in all patients. Perioperative ultrasonography was used for 3 intraparenchymal tumors. Hypertension and hypokalemia resolved within 1 week after surgery. At a mean followup of 98 months (range 24 to 204) no tumor recurrence was documented.