Biomedical subjects

R D Cespedes

Publications and source records attributed to R D Cespedes.

18 recordsLinked to original sources

PubMed1998

A followup on transurethral collagen injection therapy for urinary incontinence.

PURPOSE: Transurethral collagen injection therapy has been used successfully in treating stress urinary incontinence due to intrinsic sphincter deficiency since United States Food and Drug Administration approval in October 1993. MATERIALS AND METHODS: Telephone interview and chart review were performed on 139 women with intrinsic sphincter deficiency documented using video urodynamics, of whom 73% had grade 3 incontinence (leakage without effort). Median followup was 18 months (range 6 to 36). Median patient age was 72 years. RESULTS: A total of 103 patients (74%) was substantially improved after collagen therapy, 29 (20%) were improved and 7 had no improvement. Of the substantially improved group 72% obtained continence after 2 or fewer injections. Of the patients 11% required a "booster" injection more than 6 months after initial treatment. Complications, such as hematuria, urinary tract infections or transient urinary retention, were rare. CONCLUSIONS: Our results confirm the safety and efficacy of transurethral collagen. Once continence is achieved further collagen therapy is rarely necessary.

Aged↗

PubMed1998

Our experience with pubovaginal slings in patients with stress urinary incontinence.

PURPOSE: Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS: A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS: The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS: Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.

Adult↗

PubMed1998

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery.

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.

Adult↗

PubMed1997

Long-term followup of incontinence and obstruction after salvage cryosurgical ablation of the prostate: results in 143 patients.

PURPOSE: We report long-term followup of patients with incontinence and obstruction after salvage cryosurgical ablation of the prostate. MATERIALS AND METHODS: We reviewed the records of 143 patients who underwent cryosurgical ablation of the prostate for treatment failure after radiation therapy. Data were collected by telephone interview with each patient and chart review. Median followup was 27 months (range 12 to 42). RESULTS: Of 107 patients who underwent cryosurgical ablation of the prostate using a commercially available urethral warmer 15 (14%) had significant obstruction or retention that required transurethral resection of the prostate in 10, of whom 6 became incontinent. Urinary incontinence occurred in 45 patients (42%) and resolved in 21 (47%), for an overall 28% long-term incontinence rate. Of 28 patients who underwent cryosurgical ablation of the prostate using an alternative urethral warmer 13 (46%) had incontinence and 15 (54%) had significant obstruction or retention. Resolution was rare and 89% of the patients are currently incontinent. Eight patients underwent 2 separate cryosurgical ablations with an 88% incontinence rate (43% overall). The double freezing technique did not increase postoperative obstruction or incontinence. CONCLUSIONS: Incontinence and urinary retention rates are increased in patients undergoing cryosurgical ablation of the prostate after failure of radiation therapy but spontaneous resolution occurs in half of the patients within 1 year if an effective urethral warmer is used. Incontinence treatments should be delayed until after this period. Postoperative incontinence and obstruction rates are significantly greater when an effective urethral warmer is not used and spontaneous resolution is rare.

Cryosurgery↗

PubMed1997

Treatment results using pubovaginal slings in patients with large cystoceles and stress incontinence.

PURPOSE: We determined the efficacy of performing a pubovaginal sling concurrently with a formal cystocele repair in patients with grade III to IV cystoceles. MATERIALS AND METHODS: We studied 42 women with grade III to IV cystoceles diagnosed by physical examination and video urodynamics. Of the patients 9 (22%) had intrinsic sphincter deficiency diagnosed by an abdominal leak point pressure of less the 60 cm. water, and 24 (57%) had type II stress incontinence with urethral hypermobility and an abdominal leak point pressure greater than 90 cm. water. A pubovaginal sling and anterior colporrhaphy were performed and, if indicated, other vaginal procedures were done at that time. RESULTS: A total of 36 patients (86%) was available for postoperative pelvic examinations performed at 3-month intervals, for a mean followup of 20.4 months (range 12 to 39). Only 3 patients had symptomatic grade III cystoceles and 2 had enteroceles. Two patients required collagen injections and 2 underwent a repeat pubovaginal sling. Therefore, all patients were continent at the time of followup. CONCLUSIONS: This study confirms that in patients with large cystoceles and stress urinary incontinence a pubovaginal sling and anterior colporrhaphy effectively treat the incontinence and reduce the cystocele. In addition, the fascial sling appears to provide additional support to the bladder base, improving the durability of the anterior colporrhaphy.

Adult↗

PubMed1997

Pubovaginal fascial slings.

The first pubovaginal fascial sling was reported in 1907, however, until recently this procedure was rarely utilized except after other incontinence procedures had failed. Currently, a pubovaginal sling is indicated as the primary incontinence procedure if intrinsic sphincter deficiency or coexisting intrinsic sphincter deficiency and urethral hypermobility are diagnosed preoperatively. Additionally, incontinence secondary to urethral hypermobility should be treated with a pubovaginal sling if the patient has a high risk of postoperative failure due to obesity, chronic cough, or repetitive strenuous activity. Pubovaginal slings are relatively easy to perform and yield reliably good results with minimal morbidity. We describe our current technique and results using pubovaginal slings for stress incontinence in women.

Aged↗

PubMed1996

Leak-point pressures.

The pressure based management of patients with neurogenic vesical dysfunction has led to greatly improved outcomes with respect to upper and lower urinary tract complications. At the heart of this management is detrusor leak-point pressure testing that verifies that a low intravesical pressure is achieved and subsequently maintained. The abdominal (or Valsalva) leak-point pressure that quantifies the degree and type of urethral sphincter dysfunction, is an essential test in selecting the appropriate treatment for stress urinary incontinence. The authors discuss the history, importance, and application of these two very different tests.

Female↗

PubMed1996

Videourodynamic studies.

Videourodynamic evaluation that incorporates radiographic imaging with simultaneous measurement of bladder and urethral pressure is the most precise method available for diagnosing complex incontinence and voiding disorders. In addition, videourodynamics has been instrumental to the development of our present knowledge about urethral and bladder function including the concepts of detrusor and abdominal leak point pressures. Although these studies are more expensive and time consuming, the authors have found videourodynamic evaluation indispensable when the diagnosis remains in question after simple urodynamics and when the studies and clinical scenario do not agree.

Aged↗

PubMed1996

Proper diagnosis: a must before surgery for stress incontinence.

Stress urinary incontinence is just one of many possible reasons for incontinence in a female patient. It is important to determine the exact etiology of the urinary incontinence because successful treatment depends on an accurate diagnosis. Many additional factors such as age, level of activity, presence and degree of pelvic prolapse, detrusor abnormalities, and coexisting medical conditions must be considered during the incontinence evaluation. The physical examination should assess urethral mobility and genital prolapse abnormalities. Bladder storage abnormalities such as poor compliance are accurately assessed using current urodynamic methods, but detrusor control abnormalities, such as detrusor instability, are not. The urodynamic evaluation is directed toward identifying and quantifying urinary leakage attributable to excursions of abdominal pressure utilizing abdominal (Valsalva) leak-point pressure testing. A focused evaluation allows the appropriate operative procedure to be selected, yielding optimal long-term results.

Cystoscopy↗

PubMed1996

Pseudosarcomatous fibromyxoid tumor of the prostate. A case report with review of the literature.

A previously healthy 42-year-old white male presented with urinary obstruction. Radiographic evaluation revealed a 4-cm prostatic mass extending into the bladder. Transrectal biopsies revealed a sarcomatoid histology with atypical spindle cells suspicious for possible sarcoma. A transurethral resection of the prostate was performed revealing a benign fibromyxoid lesion with spindle cell proliferation. Postoperatively, the patient voided normally with no evidence of recurrence on follow-up of over 1 year. The clinical presentation and histologic features are consistent with pseudosarcomatous fibromyxoid tumor, a rare but benign lesion which has previously been mistaken for a malignant prostatic sarcoma. It is important for the urologist to recognize this benign process so that radical procedures are not performed.

Adult↗

PubMed1996

Bladder preservation and continent urinary diversion in T3b transitional cell carcinoma of the bladder.

The patient with T3b transitional cell carcinoma (TCC) of the bladder has traditionally been treated with radical cystectomy and urinary diversion, but initial success with systemic chemotherapy and renewed interest in quality-of-life issues has increased interest in bladder preservation treatments. Unfortunately, despite multiple trials using limited surgical procedures and neoadjuvant or adjuvant chemotherapy, no combined modality has consistently improved survival over the achieved with radical cystectomy alone in patients with T3b disease. Additionally, continent stomal diversions and orthotopic neobladders allow almost normal continence and voiding in both male and female patients, which calls into question the need for bladder preservation. Although no single treatment modality or urinary diversion is right for all patients, a radical cystectomy with continent diversion provides the best chance for survival and allows the best postoperative quality of life. If bladder preservation treatments are used, inclusion in a clinical trial is recommended.

Carcinoma, Transitional Cell↗

PubMed1996

Modified Ingelman-Sundberg bladder denervation procedure for intractable urge incontinence.

PURPOSE: We determined the efficacy of the modified Ingelman-Sundberg procedure in women with urge incontinence and intractable detrusor instability. MATERIALS AND METHODS: Women with urge incontinence and detrusor instability, in whom medical and behavioral therapy failed, received transvaginal local anesthesia to block the terminal pelvic nerve branches to the bladder. Urge incontinence resolved temporarily in 25 patients, who subsequently underwent modified Ingelman-Sundberg transvaginal bladder denervation. All patients underwent preoperative urodynamic evaluation but documented detrusor instability was not a requirement for surgery. RESULTS: Of the patients 16 (64%) were cured of urge incontinence with substantial relief of detrusor instability, 2 (8%) had temporary improvement and 7 (28%) had no change. No patient who was cured required further surgery (mean followup 14.8 months, range 4 to 30). Use of anticholinergic agents also decreased dramatically: 5 patients used no, 9 used 1 and 2 used 2 medications. Detrusor instability was documented in 44% of the patients and was not predictive of operative outcome. There were no major complications of the procedure. Operative time was approximately 15 minutes. CONCLUSIONS: In patients with urge incontinence and medically refractory detrusor instability, with few simple choices for treatment, the modified Ingelman-Sundberg procedure is an excellent surgical option that yields good results with minimal morbidity.

Adult↗

PubMed1995

Protection of the germinal epithelium in the rat from the cytotoxic effects of chemotherapy by a luteinizing hormone-releasing hormone agonist and antiandrogen therapy.

OBJECTIVES: The protection of spermatogenesis during chemotherapy using an antiandrogen and a luteinizing hormone-releasing hormone (LHRH) agonist was examined in the rat. Previous studies using LHRH agonists alone have been inconclusive, as both protective and deleterious effects on the germinal epithelium have been reported. Flutamide has not previously been used in this manner but theoretically should protect the germinal epithelium, since flutamide rapidly blocks testosterone at the cellular level and also minimizes the testosterone "flare" when LHRH agonist therapy is initiated. METHODS: Mature Sprague-Dawley rats were pretreated with flutamide, sustained-release goserelin acetate (Zoladex), or a combination of flutamide and sustained-release goserelin acetate for 14 days before 4 weekly doses of procarbazine were initiated. The seminiferous tubules were evaluated histologically after a 90-day regeneration period using the stem cell assay test. RESULTS: After treatment with procarbazine alone, only 43% of the seminiferous tubules were active; however, 80% were active if protected with flutamide, 91% if protected with sustained-release goserelin acetate, and 95% if protected with both flutamide and goserelin acetate. CONCLUSION: Flutamide, sustained-release goserelin acetate, and a combination of these agents were effective in protecting the germinal epithelium of the rat during chemotherapy. A combination of flutamide and goserelin acetate provided the best protection. This study demonstrates for the first time the protective effect of flutamide and flutamide with goserelin acetate on the germinal epithelium during chemotherapy.

Animals↗

PubMed1995

Herniation of the urinary bladder: a complication of traumatic pubic symphysis diastasis.

Bladder rupture and urethral disruption are relatively common injuries associated with pelvic trauma; however, bladder herniation into a public symphysis diastasis is an unusual sequelae of pelvic trauma. We report a case of anterior bladder wall herniation into a traumatic pubic diastasis and review the literature. Recommendations focusing on avoiding possible urinary bladder complications associated with closed reduction and external fixation of the diastasis are offered.

Adult↗

PubMed1995

The significance of hematuria in patients infected with the human immunodeficiency virus.

PURPOSE: We determined the importance of hematuria in patients infected with the human immunodeficiency virus (HIV). MATERIALS AND METHODS: The records of 1,326 HIV infected patients with yearly evaluations were reviewed for hematuria and evaluation results. Mean followup was 2.1 years. RESULTS: A total of 331 patients (25.0%) had 1 episode of hematuria and 67 were evaluated with 5 significant diagnoses made. Management was affected in only 3 of these patients. No occult genitourinary tumors were found. CONCLUSIONS: In young, asymptomatic, HIV infected patients with microscopic hematuria a urological evaluation can be safely omitted in the presence of normal renal function and a benign urological history.

Adult↗

PubMed1994

Cryptic presentations of germ cell tumors.

The records of 636 patients who were treated for carcinoma of the testis were reviewed. Of these patients, 61 (9.6 percent) presented with extratesticular complaints. In order of decreasing frequency, the complaints were pain (abdominal, back or groin), gynecomastia or mastodynia, pulmonary complaints, enlarged lymph nodes or a nontesticular mass, swelling of the lower extremity or neurologic changes. A substantial number of these patients were initially misdiagnosed and underwent a surgical procedure. Of importance, most of these patients had either abnormal testicular examination results, elevated markers or a history of cryptorchidism. The data suggest that patients with germ cell tumors, even when presenting with cryptic complaints, can readily be diagnosed if a high level of suspicion is maintained, a careful testicular examination is performed and tumor markers obtained. This frequently makes a diagnostic abdominal exploration or other surgical interventions unnecessary.

Adolescent↗

PubMed1993

Chylothorax as a complication of radical nephrectomy.

We report a case of chylo-retroperitoneum and chylothorax following an uneventful left radical nephrectomy for renal cell carcinoma, and propose the mechanism of an infradiaphragmatic lymphatic injury with fistulous connection into the chest. Treatment with oral medium chain triglycerides was unsuccessful. Subsequently, total parenteral nutrition in conjunction with chest drainage, retroperitoneal drainage and sclerotherapy successfully treated the chylothorax. To our knowledge chylothorax following radical nephrectomy has not been reported previously in the literature.

Aged↗

PubMed1992

An atypical case of brucellosis in a Turkish national.

Brucellosis is an endemic disease in many of the countries in which military personnel are stationed, including the Middle East, where thousands are deployed. The signs and symptoms of brucellosis are often nonspecific and diagnosis requires a high index of suspicion. This case report involves a Turkish national with an unusual febrile illness, subsequently diagnosed as brucellosis. The presentation, diagnosis, and treatment are discussed. The special relevance to the military physician is emphasized.

Adult↗