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Modified Pereyra bladder neck suspension
LETTERS TO THE EDITOR
MODIFIED PEREYRA BLADDER NECK SUSPENSION Tothe Editor: E. Forneret and G. E. Leach in their article, Cost-Effective Treatment of Female Stress Urinary Continence: Modified Pereyra Bladder Neck Suspension, published in the April (vol. 25, page 365, 1985) issue of UROLOGY, address an ever more important aspect of current practice-cost containment with the preservation of the quality of care. The modified Pereyra bladder neck suspension (MBPN) has almost completely replaced the Marshall-Marchetti-Krantz (MMK) procedure in our Center. There are some very cogent reasons for the change, not the least of which is the question of cost. We have used a technique that is basically faithful to the excellent one reported by Boyd and Raz.* The vaginal packing and Foley catheter are removed the morning after surgery. Ambulation is permitted immediately after recovery from the anesthetic. Our experience amply supports the contention of Forneret and Leach of decreased analgesic requirements, decreased use of blood transfusion, decreased incidence of significant perioperative complications, decreased use of intravenous fluid administration, and decreased hospital stay. We agree entirely that preoperative education in the technique of clean intermittent selfcatheterization (CIC) is an important aspect of the MPBNS . We have performed the MPBNS as an outpatient procedure and believe that certain well selected and motivated patients may safely be managed in this fashion. Preoperative education in CIC is essential, and rapidly successful mastery of this identifies potential candidates for outpatient surgery. Patients returning home after surgery are instructed to remove the vaginal packing and Foley catheter in the morning and commence CIC at 3 hourly intervals until the p stvoid residual is less than 100 ml. We are fortunate E that these women can be followed up in an ambulatory clinic as often as necessary Five other points are worthy of note: 1. The MPBNS may involve a much decreased period of recumbency and consequently lower risk of venous thrombosis. 2. The MPBNS is ideally suited to regional anesthetic techniques. 3. The fact that the MPBNS is a minimal surgical intervention makes it possible to help many women with inconvenient stress incontinence who were reluctant to agree to more invasive repairs. *Boyd SD, and Raz S: Needle bladder neck suspension for female stress incontinence, Urol Clin North Am 11: 357 (1984).
UROLOGY
/ JULY 1985
I VOLUME XXVI, NUMBER 1
4. It is a technique ideally suited to revisions and patients with previous pelvic surgery including MMK. 5. It is very well tolerated even in the grossly obese patient. Jeremy P. W. Heaton, M.D. Alvaro Morales, M.D. Queens University Kingston, Ontario K7L 2V7, Canada
USE OF THE CAVITRON IN RENAL SURGERY To the Editor: In reference to the articles on the Cavitron ultrasonic surgical aspirator (vol. 22, page 157, 1983; vol. 23, pages 417-426, 1984) in UROLOGY W. J. Hodgson has reported on the successful use of the Cavitron in general surgery, especially hepatic surgery. Several attempts by Hodgson to demonstrate the usefulness of this device in renal surgery were unsuccessful, secondary to significant bleeding. We attempted to confirm Chopp’s results. Applying the techniques developed by Hodgson and Chopp, facility with the instrument is easily obtained with perfused and unperfused cadaveric porcine kidneys. The Cavitron was then used to perform heminephrectomies and anatrophic lithotomies on live anesthetized animals. The Cavitron was then used in the clinical setting to perform an anatrophic lithotomy, a heminephrectomy, and a nephrectomy for carcinoma in a pelvic cake kidney. Our preliminary work represents a wide variation of renal surgery. Our results in humans in the clinical settings mentioned were similar to Hodgson’s. The larger arterioles depicted by Chopp could be identified, skeletonized, and controlled without difficulty. The difficulty is encountered with venous bleeding from vessels of small caliber. Visualization was difficult, the suction of the device inadequate, and the procedure time-consuming. We believe that a significant amount of lateral traction and compression on the edges of the incision is necessary for visualization and dissection. The parenchyma is easily torn and damaged by the traction and compression. The difficulties with poor visualization and bleeding could not be averted by variations in technique, instrument power settings (from the 0.5 setting recommended), or more gentle tissue handling. Perhaps the majority of the bleeding is from the 97
MODIFIED PEREYRA BLADDER NECK SUSPENSION Tothe Editor: E. Forneret and G. E. Leach in their article, Cost-Effective Treatment of Female Stress Urinary Continence: Modified Pereyra Bladder Neck Suspension, published in the April (vol. 25, page 365, 1985) issue of UROLOGY, address an ever more important aspect of current practice-cost containment with the preservation of the quality of care. The modified Pereyra bladder neck suspension (MBPN) has almost completely replaced the Marshall-Marchetti-Krantz (MMK) procedure in our Center. There are some very cogent reasons for the change, not the least of which is the question of cost. We have used a technique that is basically faithful to the excellent one reported by Boyd and Raz.* The vaginal packing and Foley catheter are removed the morning after surgery. Ambulation is permitted immediately after recovery from the anesthetic. Our experience amply supports the contention of Forneret and Leach of decreased analgesic requirements, decreased use of blood transfusion, decreased incidence of significant perioperative complications, decreased use of intravenous fluid administration, and decreased hospital stay. We agree entirely that preoperative education in the technique of clean intermittent selfcatheterization (CIC) is an important aspect of the MPBNS . We have performed the MPBNS as an outpatient procedure and believe that certain well selected and motivated patients may safely be managed in this fashion. Preoperative education in CIC is essential, and rapidly successful mastery of this identifies potential candidates for outpatient surgery. Patients returning home after surgery are instructed to remove the vaginal packing and Foley catheter in the morning and commence CIC at 3 hourly intervals until the p stvoid residual is less than 100 ml. We are fortunate E that these women can be followed up in an ambulatory clinic as often as necessary Five other points are worthy of note: 1. The MPBNS may involve a much decreased period of recumbency and consequently lower risk of venous thrombosis. 2. The MPBNS is ideally suited to regional anesthetic techniques. 3. The fact that the MPBNS is a minimal surgical intervention makes it possible to help many women with inconvenient stress incontinence who were reluctant to agree to more invasive repairs. *Boyd SD, and Raz S: Needle bladder neck suspension for female stress incontinence, Urol Clin North Am 11: 357 (1984).
UROLOGY
/ JULY 1985
I VOLUME XXVI, NUMBER 1
4. It is a technique ideally suited to revisions and patients with previous pelvic surgery including MMK. 5. It is very well tolerated even in the grossly obese patient. Jeremy P. W. Heaton, M.D. Alvaro Morales, M.D. Queens University Kingston, Ontario K7L 2V7, Canada
USE OF THE CAVITRON IN RENAL SURGERY To the Editor: In reference to the articles on the Cavitron ultrasonic surgical aspirator (vol. 22, page 157, 1983; vol. 23, pages 417-426, 1984) in UROLOGY W. J. Hodgson has reported on the successful use of the Cavitron in general surgery, especially hepatic surgery. Several attempts by Hodgson to demonstrate the usefulness of this device in renal surgery were unsuccessful, secondary to significant bleeding. We attempted to confirm Chopp’s results. Applying the techniques developed by Hodgson and Chopp, facility with the instrument is easily obtained with perfused and unperfused cadaveric porcine kidneys. The Cavitron was then used to perform heminephrectomies and anatrophic lithotomies on live anesthetized animals. The Cavitron was then used in the clinical setting to perform an anatrophic lithotomy, a heminephrectomy, and a nephrectomy for carcinoma in a pelvic cake kidney. Our preliminary work represents a wide variation of renal surgery. Our results in humans in the clinical settings mentioned were similar to Hodgson’s. The larger arterioles depicted by Chopp could be identified, skeletonized, and controlled without difficulty. The difficulty is encountered with venous bleeding from vessels of small caliber. Visualization was difficult, the suction of the device inadequate, and the procedure time-consuming. We believe that a significant amount of lateral traction and compression on the edges of the incision is necessary for visualization and dissection. The parenchyma is easily torn and damaged by the traction and compression. The difficulties with poor visualization and bleeding could not be averted by variations in technique, instrument power settings (from the 0.5 setting recommended), or more gentle tissue handling. Perhaps the majority of the bleeding is from the 97