Biomedical subjects
J G Blaivas
Publications and source records attributed to J G Blaivas.
Standards of efficacy for evaluation of treatment outcomes in urinary incontinence: recommendations of the Urodynamic Society.
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Definition and classification of urinary incontinence: recommendations of the Urodynamic Society.
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Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association.
PURPOSE: The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures. RESULTS: The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings. CONCLUSIONS: The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.
The bladder is an unreliable witness.
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Obstructive uropathy in the male.
BPH is not synonymous with prostatic obstruction. The cause of symptoms in men with prostatism is multifactorial, comprising four conditions: (1) prostatic urethral obstruction, (2) impaired detrusor contractility, (3) detrusor instability, and (4) sensory urgency. Some men have an isolated obstruction at the vesical neck, termed primary vesical neck obstruction, that may have a different cause from that of BPH, and others have a learned voiding dysfunction wherein they are unable to relax completely during micturition. There is no simple means of distinguishing the various conditions that underlie voiding symptoms in men. Neither simple cystometry nor uroflow suffice. Detrusor pressure and uroflow studies usually are definitive, but more sophisticated analysis may be necessary.
Physiological principles for surgical correction of detrusor dysfunction.
Urinary incontinence may be the result of various forms of detrusor overactivity. Several surgical therapies have been devised, but with the exception of procedures to relieve urethral obstruction, none abolishes the overactivity or restores normal micturition. In general, ablative neurosurgery is considered only in patients with chronic neurologic disease. Bladder augmentation is useful in selected patients. The indications for urinary diversion in patients with detrusor overactivity and urge incontinence are quite limited.
Vaginal flap reconstruction of the urethra and vesical neck in women: a report of 49 cases.
PURPOSE: A retrospective study was done to evaluate the results of a 1-stage urethral reconstruction in women. MATERIALS AND METHODS: Of 49 consecutive women who presented with anatomical damage to the urethra or vesical neck 48 underwent urethral and/or vesical neck reconstruction with vaginal flaps. A Martius labial fat pad flap was used in 47 patients, a gracilis flap in 1 and an anterior bladder tube in 1. In 41 patients the anti-incontinence procedure consisted of a fascial pubovaginal sling placed over the labial fat pad flap without tension. In 5 patients a modified Pereyra operation was done and 1 underwent a Kelly plication. Followup ranged from 1 to 11 years. RESULTS: Postoperatively continence was obtained in 42 of 49 patients (87%). The initial procedure failed in 7 patients and a secondary procedure was successful in 6. Of the 5 initial patients who underwent a modified Pereyra operation 3 had postoperative stress incontinence and all were cured subsequently by a pubovaginal sling. CONCLUSIONS: A 1-stage vaginal flap reconstruction and pubovaginal sling procedure is effective in women with extensive vesical neck and/or urethral damage.
Urodynamic findings in patients with diabetic cystopathy.
To ascertain the relationship between voiding dysfunction associated with diabetes and bladder and sphincter behavior, the video urodynamic studies of 182 patients were retrospectively analyzed. Patients were classified based on urodynamic diagnosis and the presence or absence of signs of sacral cord involvement. Urodynamic findings were classified as either detrusor hyperreflexia, impaired detrusor contractility, detrusor areflexia, indeterminate and normal. The results indicate that mean bladder capacity was 485 +/- 89.3 ml. with a mean first sensation of filling of 298 +/- 67.4 ml. Of the 182 patients 100 (55%) had detrusor hyperreflexia, 42 (23%) had impaired detrusor contractility, 20 (11%) had indeterminate findings, 19 (10%) had detrusor areflexia and 1 (1%) was normal. Bladder outlet obstruction occurred in 66 patients (36%), all men (57%). The diagnosis was isolated in 24 patients (36%) or in combination with another diagnosis in 42 (74%). However, if one considers the presence of sacral cord signs (42 patients), the most common urodynamic diagnoses were either impaired detrusor contractility in 21 (50%) or detrusor areflexia in 10 (24%). These data suggest that classical diabetic cystopathy is not the most common urodynamic findings in patients with diabetes mellitus and voiding dysfunction, and in fact these patients present with variable pathophysiological findings. These findings demonstrate the importance of urodynamic studies in diagnosing voiding dysfunction in diabetics before initiation of therapy.
Preliminary assessment of the incontinent woman.
Assessment of urinary incontinence begins with a thorough history and physical examination. This article reviews the collection of subjective, semi-objective, and objective data that allows for comprehensive evaluation of the incontinent female patient. These results will help direct further evaluation and develop an efficient and effective treatment plan.
Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches.
We reviewed retrospectively 24 consecutive women who presented with a vesicovaginal fistula repaired by a single surgeon between 1989 and 1993. All patients underwent preoperative investigation, including cystoscopy, excretory urography and bilateral retrograde pyelography. Followup ranged from 6 months to 5 years. Postoperatively, 96% of the women were cured. Two patients had persistent symptomatic detrusor instability and 1 had mild stress incontinence. In 1 woman a vaginal repair failed and she was subsequently cured after an abdominal repair. Five patients presented 6 to 12 months after fistula formation. Among the other 17 patients the average interval from pelvic surgery to vesicovaginal fistula repair was 10.8 weeks. Indications for abdominal repair were indurated vaginal epithelium approximately 2 cm. in circumference around the fistula, a vault fistula with poor vaginal exposure and fistulas involving the ureters. Surgical timing and route of repair are best tailored to the individual patient.
Persistence or recurrence of symptoms after transurethral resection of the prostate: a urodynamic assessment.
Approximately 15 to 20% of patients who undergo transurethral resection of the prostate for benign prostatic hyperplasia have persistent or recurrent voiding symptoms requiring further therapy. To elucidate the etiology of these voiding abnormalities, the urodynamic findings of 129 consecutive men (mean age 72 years) with post-transurethral resection voiding symptoms were retrospectively analyzed with respect to symptoms, uroflowmetry and synchronous video pressure-flow cystometry. Our findings revealed obstruction in 38% of the patients, impaired contractility in 25% and intrinsic sphincter deficiency in 8%. Among 80 patients without neurological disorders involuntary bladder contractions were detected in 50%. However, in 49 patients with neurological disorders involuntary bladder contractions were detected in 76%. This difference was statistically significant. There were 15 patients who failed 2 or more transurethral resections of the prostate, and involuntary bladder contractions were detected in 80%, obstruction in 27%, impaired contractility in 27% and sphincteric incontinence in 20%. Our study reveals residual or recurrent obstruction to be a contributing factor in less than half of all patients who fail transurethral resection of the prostate. Furthermore, patients with a concomitant neurological disorder and those who have undergone more than 1 transurethral resection of the prostate have a significantly higher incidence of involuntary bladder contractions. These results underscore the importance of obtaining complete urodynamic assessment in patients with persistent or recurrent voiding symptoms following transurethral resection of the prostate to guide appropriate therapy.
Volvulus of the ileal conduit: a late complication.
We report 2 cases of ileal conduit volvulus presenting as a late complication. The importance of early diagnosis and surgical intervention is discussed.
Periurethral injection of autologous fat for the treatment of sphincteric incontinence.
A total of 15 women with stress incontinence and 6 men with post-prostatectomy sphincteric incontinence underwent periurethral injection of autologous fat while under local anesthesia. The fat was harvested from the abdominal wall by liposuction. Preoperative evaluation consisted of a micturition diary, questionnaire, semiquantitative pad test, cystoscopy and urodynamics. Sequential injections were performed at 1 to 3-month intervals. Results were assessed by subjective patient scores, pad tests and clinical evaluation performed at intervals. Followup was 12 to 30 months (mean 18). Only 1 man and none of the women with urethral hypermobility had lasting improvement. Of the 15 women 12 had intrinsic sphincteric deficiency (type 3 stress incontinence) and they were our most successful group. Of the 12 women 10 (83%) were improved (mean score of 8.8-7 before injection compared to 1.87 after injection) at 1 month following the initial injection. Of the 9 patients who continued with the treatment 7 (78%) noticed lasting improvement objectively and subjectively after 1 to 4 injections (mean 2.4). We believe that this technique shows sufficient promise as an alternative therapy for sphincteric incontinence to warrant continued clinical investigation.
Urological and sexual problems in multiple sclerosis.
Urologic dysfunction is a common and devastating feature of multiple sclerosis (MS). For many MS patients, urinary symptoms may be the most socially disabling features of the illness. In this chapter, we describe the urologic dysfunctions seen in MS, and discuss appropriate management for patients with MS. Sexual dysfunction is also common in MS and will be discussed in this chapter. Several safe and effective non-surgical modalities are now widely available for the treatment of erectile dysfunction.
Urinary symptoms and symptom scores.
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Maximum urinary flow rate by uroflowmetry: automatic or visual interpretation.
We measured the maximum urinary flow rate monthly for 1 year by uroflowmetry in 1,645 patients in a double-blind, placebo-controlled study of finasteride therapy for benign prostatic hyperplasia. Patients were randomized to receive placebo (555) or finasteride (1,090). A total of 23,857 flow measurements was obtained. Because of the presence of artifacts on many uroflow curves, we read the maximum urinary flow rate values manually and compared them to the values provided electronically by the uroflowmeter. On average, the manually read values were 1.5 ml. per second lower than the machine read values. Artifacts causing a difference of 2 ml. per second or more between the 2 methods were found in 20% and of more than 3 ml. per second in 9% of the tracings. The difference between treatment groups in mean maximum urinary flow rate change at the end of the study was the same with both reading methods. However, confidence intervals were 15 to 25% larger for the machine read compared to the manually read values. This larger variability in machine read maximum urinary flow rate has a marked negative impact on the power of statistical tests to assess any given difference in maximum urinary flow rate between treatment groups. Furthermore, it increases sample size requirements by 50% to achieve any given statistical power. We conclude that maximum urinary flow rate artifacts contribute significantly to the variability of maximum urinary flow rate measurement by uroflowmetry. Manual reading of the maximum urinary flow rate eliminates an important fraction of such variability.