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Stenting the Urinary System
BOOK REVIEWS
the bladder was removed for histologic examination. A questionnaire revealed a significant difference (P <0.01) regarding voiding symptom severity between symptomatic IC patients and both normal volunteers and IC patients in remission. There was no statistically significant difference among groups of rabbits in cystoscopic bladder appearance, bladder capacity, urea permeability, or bladder histology. If a urine-borne factor is in part responsible for IC symptoms, the rabbit bladder must be filled with urine to near capacity to be able to detect a difference between IC and normal urine in this rabbit bladder bioassay. Editorial Comment: Most authors are reluctant to publish results that contradict previous results and hypotheses of their own. These authors are not. Congratulations! Alan J. Wein, M.D. Sphincteric Incontinence: The Primary Cause of Post-Prostatectomy Incontinence in Patients With Prostate Cancer
M. G. DESAUTEL, R. ~ O O AND R G. H. BADLANI, Division of Neurourology and Bioprosthetics, Long Zsland Jewish Medical Center, New Hyde Park, New York, and Sanjay Gandhi Post Graduate Institute ofMedical Science, Lucknow, India Neurourol. Urodynam., 16: 153-160, 1997 Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom seventy. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%)and a major contributor in 14 others (369). Twenty-seven patients (69%)had VLPP less than 103 cmH,O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH,O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%)patients. Bladder dysfunction characterized by detrusor instability andlor decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of postprostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence. Editorial Comment: These results coincide with my experience. In the vast majority of men who do not leak before prostatectomy and leak afterwards, which comprises almost everyone with post-prostatectomy incontinence, iatrogenic sphincteric compromise is the main cause. Of this particular group 37 patients ( 9 5 4 ) had total sphincteric incontinence. I believe that in such a patient, especially if the bladder has been defunctionalized for some time, it is hard to implicate a urodynamic finding of an involuntary bladder contraction or decreased compliance as a contributory cause of incontinence following prostatectomy. Detrusor instability in this series was the sole cause of incontinence in only 1 patient (3%)and poor compliance alone was not the sole cause in any patient. Alan J. Wein. M.D.
BOOK REVIEWS Stenting the Urinary System
D. YACHIA, Oxford: Isis Medical Media, 500 pages, 1998 This book is designed to provide a comprehensive review of urinary tract stenting devices. It was written by an international, multidisciplinary group of authors and contains multiple illustrations to communicate stent designs and related techniques. Included in the body are the history, current applications, materials, complications, as well as the future of urological stents. The book is unique, as there has not been a previous textbook covering such a wide variety of related topics, and important since urologists are dependent on many different stenting devices. Although most clinicians are familiar with the indications for and methods of ureteral stent insertion, they have limited knowledge of nonureteral stents as well as the basis for the technology and materials used. Although the text is comprehensive, the information is scattered and redundant largely due to the format.
2041
2042
BOOK REVIEWS
To address specific topics the text contains 66 highly focused chapters, which means that one must read multiple chapters to obtain an overview of a single topic. Repetition results as each author has included a separate introduction which usually contains the same background information and references as in other related chapters. Fewer, more comprehensive chapters probably would have been more efficient to cover the individual topics. A second related criticism is the inclusion of chapters, such as surgical techniques other than stent insertionhemoval, that do not appear related to the goals of the textbook. An unavoidable shortcoming is that, due to the rapidly changing nature of urological technology, some information is omitted or outdated. In addition, since followup was longer for certain procedures, especially with regard to prostatic stents, results and recommended use do not reflect current urological practice. For such topics regularly released updates are required to provide up-to-date information. The global perspective and comprehensive nature make this book unique, and I recommend it as a complement to any urological library. Thomas W. Jarrett, M . R. James Buchanan Brady Urological Znstitute Johns Hopkins Medical Institutions Baltimore, Maryland Glenn’s Urologic Surgery,5th ed.
s. D. GRAHAI\I, JR.
AND J. F. GLENN, Philadelphia: Lippincott-Raven Publishers, 1,149 pages, 1998 In this fifth edition Graham is now the primary editor, since the reigns have been passed from Glenn. Since the first edition was released in 1969, Urologic Surgery has held true to the philosophy that urology is a surgical discipline, and this is maintained under the guidance of Graham. The book is divided into 14 sections, each under the direction of 1of 15 associate editors. Every section is composed of several chapters authored by various leaders in urology. The text provides a nice balance of written descriptions of numerous urological diagnoses along with pictoral outlines of appropriate surgical therapy. The 147 chapters are organized to include a general discussion of the topic as well as indications for and alternatives to surgery, specific technique and outcomes. Unlike most urological textbooks the emphasis is clearly on surgical techniques, although these related discussions go beyond the scope of the usual surgical atlas. Particular techniques unique to the practicing urologist are addressed, including endoscopy and retroperitoneal laparoscopy. Perhaps the most unusual section addresses current frontiers in urology. These chapters include frank discussion of robotics, cryosurgery, microwave thermotherapy and interstitial laser treatment. This book continues to be a valuable reference not only for residents, but for the practicing urologist as well. It is an excellent source of the information necessary for determining appropriateness of surgery as well as for understanding the risks, benefits, alternatives and complications necessary for patient discussions. John H. Lynch, M. D. Georgetown Medical Center Washington, D. C.
the bladder was removed for histologic examination. A questionnaire revealed a significant difference (P <0.01) regarding voiding symptom severity between symptomatic IC patients and both normal volunteers and IC patients in remission. There was no statistically significant difference among groups of rabbits in cystoscopic bladder appearance, bladder capacity, urea permeability, or bladder histology. If a urine-borne factor is in part responsible for IC symptoms, the rabbit bladder must be filled with urine to near capacity to be able to detect a difference between IC and normal urine in this rabbit bladder bioassay. Editorial Comment: Most authors are reluctant to publish results that contradict previous results and hypotheses of their own. These authors are not. Congratulations! Alan J. Wein, M.D. Sphincteric Incontinence: The Primary Cause of Post-Prostatectomy Incontinence in Patients With Prostate Cancer
M. G. DESAUTEL, R. ~ O O AND R G. H. BADLANI, Division of Neurourology and Bioprosthetics, Long Zsland Jewish Medical Center, New Hyde Park, New York, and Sanjay Gandhi Post Graduate Institute ofMedical Science, Lucknow, India Neurourol. Urodynam., 16: 153-160, 1997 Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom seventy. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%)and a major contributor in 14 others (369). Twenty-seven patients (69%)had VLPP less than 103 cmH,O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH,O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%)patients. Bladder dysfunction characterized by detrusor instability andlor decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of postprostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence. Editorial Comment: These results coincide with my experience. In the vast majority of men who do not leak before prostatectomy and leak afterwards, which comprises almost everyone with post-prostatectomy incontinence, iatrogenic sphincteric compromise is the main cause. Of this particular group 37 patients ( 9 5 4 ) had total sphincteric incontinence. I believe that in such a patient, especially if the bladder has been defunctionalized for some time, it is hard to implicate a urodynamic finding of an involuntary bladder contraction or decreased compliance as a contributory cause of incontinence following prostatectomy. Detrusor instability in this series was the sole cause of incontinence in only 1 patient (3%)and poor compliance alone was not the sole cause in any patient. Alan J. Wein. M.D.
BOOK REVIEWS Stenting the Urinary System
D. YACHIA, Oxford: Isis Medical Media, 500 pages, 1998 This book is designed to provide a comprehensive review of urinary tract stenting devices. It was written by an international, multidisciplinary group of authors and contains multiple illustrations to communicate stent designs and related techniques. Included in the body are the history, current applications, materials, complications, as well as the future of urological stents. The book is unique, as there has not been a previous textbook covering such a wide variety of related topics, and important since urologists are dependent on many different stenting devices. Although most clinicians are familiar with the indications for and methods of ureteral stent insertion, they have limited knowledge of nonureteral stents as well as the basis for the technology and materials used. Although the text is comprehensive, the information is scattered and redundant largely due to the format.
2041
2042
BOOK REVIEWS
To address specific topics the text contains 66 highly focused chapters, which means that one must read multiple chapters to obtain an overview of a single topic. Repetition results as each author has included a separate introduction which usually contains the same background information and references as in other related chapters. Fewer, more comprehensive chapters probably would have been more efficient to cover the individual topics. A second related criticism is the inclusion of chapters, such as surgical techniques other than stent insertionhemoval, that do not appear related to the goals of the textbook. An unavoidable shortcoming is that, due to the rapidly changing nature of urological technology, some information is omitted or outdated. In addition, since followup was longer for certain procedures, especially with regard to prostatic stents, results and recommended use do not reflect current urological practice. For such topics regularly released updates are required to provide up-to-date information. The global perspective and comprehensive nature make this book unique, and I recommend it as a complement to any urological library. Thomas W. Jarrett, M . R. James Buchanan Brady Urological Znstitute Johns Hopkins Medical Institutions Baltimore, Maryland Glenn’s Urologic Surgery,5th ed.
s. D. GRAHAI\I, JR.
AND J. F. GLENN, Philadelphia: Lippincott-Raven Publishers, 1,149 pages, 1998 In this fifth edition Graham is now the primary editor, since the reigns have been passed from Glenn. Since the first edition was released in 1969, Urologic Surgery has held true to the philosophy that urology is a surgical discipline, and this is maintained under the guidance of Graham. The book is divided into 14 sections, each under the direction of 1of 15 associate editors. Every section is composed of several chapters authored by various leaders in urology. The text provides a nice balance of written descriptions of numerous urological diagnoses along with pictoral outlines of appropriate surgical therapy. The 147 chapters are organized to include a general discussion of the topic as well as indications for and alternatives to surgery, specific technique and outcomes. Unlike most urological textbooks the emphasis is clearly on surgical techniques, although these related discussions go beyond the scope of the usual surgical atlas. Particular techniques unique to the practicing urologist are addressed, including endoscopy and retroperitoneal laparoscopy. Perhaps the most unusual section addresses current frontiers in urology. These chapters include frank discussion of robotics, cryosurgery, microwave thermotherapy and interstitial laser treatment. This book continues to be a valuable reference not only for residents, but for the practicing urologist as well. It is an excellent source of the information necessary for determining appropriateness of surgery as well as for understanding the risks, benefits, alternatives and complications necessary for patient discussions. John H. Lynch, M. D. Georgetown Medical Center Washington, D. C.