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With an adequate case volume and committed expertise this procedure can be performed successfully with decreased morbidity. Laparoscopic live donor nephrectomy is in the midst of making the transition from a developmental to an established technique, and patients are interested. Transplant centers need to confront this issue directly. Just as a variety of immunosupressive regimens are available that can be tailored to individual needs, appropriate judgements regarding the technique for kidney removal should also be applied, while always adhering to the basic principles of live donor nephrectomy. David A. Goldfarb, M.D. 1. Gill, I. S., Uzzo, R. G., Hobart, M. G. et al: Laparoscopic retroperitoneal live donor nephrectomy for purposes of allotransplantation and autotransplantation. J Urol, 164: 150, 2000

VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY Can Uroflowmetry Patterns in Women be Reliably Interpreted? T.-P. CHOU, E. GORTON, S. L. STANTON, M. ATHERTON, K. BAESSLER AND G. RIENHARDT, Military General Hospital, Taipei, Taiwan, Republic of China, St. George’s Hospital Medical School, London, United Kingdom, and Tygerberg Hospital, Cape Town, South Africa Int Urogynecol J, 11: 142–147, 2000 Our aim was to investigate the proposition that uroflowmetry patterns can be reliably interpreted and correspond with specific urodynamic diagnoses. Uroflowmetry traces from 129 women with diagnoses of either genuine stress incontinence or detrusor instability were interpreted by four physicians with a minimum of 6 months experience in urogynecology. To test intraobserver variability, the traces were classified a second time 8 weeks later. Inter- and intraobserver variability was calculated by ␬ analysis. There was marked intra- and interobserver variability in classification of traces, but no evidence of a correlation between urodynamic diagnosis and uroflowmetry pattern. Neither peak flow, total voided volume nor rate of acceleration of flow correlated with diagnosis. Although flow rates are important in predicting possible problems following surgery for stress incontinence, there is no evidence that flow patterns can be used as a screening test for specific urodynamic diagnoses. Editorial Comment: This study focused on women with detrusor instability or stress incontinence, concluding that patients with 1 entity could not be distinguished from those with the other by uroflowmetry. These findings are not unexpected, as flowmetry is a study that integrates the activity of the bladder and outlet during the emptying phase of micturition. Furthermore, the study suggests that intra-observer and interobserver reliability of classification of uroflowmetry patterns in women is, at best, moderate. Alan J. Wein, M.D. Reproducibility of Cystometry in Overactive Detrusor Y. HOMMA, Y. KONDO, S. TAKAHASHI, T. KITAMURA Hospital, Tokyo, Japan

AND

K. KAWABE, Department of Urology, Tokyo University

Eur Urol, 38: 681– 685, 2000 Objective: To examine the reproducibility of cystometry in the overactive detrusor. Methods: The study sample involved 30 patients of the placebo arm in double-blind clinical trials for an overactive detrusor. They had demonstrated detrusor overactivity and underwent the second cystometry after 2– 4 weeks. Nonparametric tests for paired data were used to examine the reproducibility of four variables: volume at first desire to void, volume at first involuntary contraction, cystometric capacity, and the maximum pressure of involuntary contraction. Percent change and within-subject standard deviation were calculated to assess intraindividual variability. Results: The second test results showed a significant and systematic change for the better. Volume variables increased by 10 –13% (p ⬍0.01), involuntary contraction was not elicited in 3 cases (10%), and the maximum contraction pressure decreased by 18% in the remaining cases. Intraindividual variability was not small. Seventeen patients (57%) demonstrated ⭌25% change in one or more variables, and the 95% confidence interval of cystometric capacity, for example, was calculated as (x ⫺57, ⫻ ⫹57), where x is a test result. No specific patients’ demographics were found related to variability. Conclusion: Repeat cystometry in the overactive detrusor is not highly reproducible and may be subject to a systematic effect for the ‘better’. Whether this is due to the placebo effect or the learning effect could not be determined.

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Editorial Comment: Although the number of patients in this study is small, I suspect that the observations would be borne out in a larger study regarding the reproducibility of cystometry in patients with urodynamic detrusor overactivity 2 to 4 weeks after an initial study. There were moderate changes in the individual cystometric variables measured and, using the classification of overactive bladder of Fall et al,1 only 67% of patients were in the same urodynamic classification at the time of the second cystometrogram. This finding has obvious implications regarding 1) the usefulness of cystometry in diagnosing “overactive detrusor” and 2) the absolute necessity for a placebo arm in clinical studies of therapy of such patients. Alan J. Wein, M.D. 1. Fall, M., Girsson, G. and Lindstrom, S.: Toward a new classification of overactive bladders. Neurourol Urodyn, 14: 635, 1995

Leak-Point Pressures T. M. LANE AND P. J. R. SHAH, Institute of Urology and Nephrology, Middlesex Hospital, London and Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom BJU Int, 86: 942–949, 2000 No Abstract Editorial Comment: This is an excellent review article on the concept, use and technique of measurement of abdominal and detrusor leak point pressures. For reasons that are unclear, the authors specify that they used a 10Fr microtip pressure transducer catheter to record intravesical pressure for abdominal leak point pressure but they did not insist on a microtip transducer for the measurement of detrusor leak point pressure. Otherwise, the article is quite clear and complete. Factors which lead to an overestimate of abdominal leak point pressure are listed as 1) rapid rate of bladder filling, 2) larger catheters, 3) pelvic prolapse, 4) poor bladder compliance and 5) lower bladder volumes. Factors which lead to an underestimate of abdominal leak point pressure include 1) larger bladder volumes, 2) rectal pressure monitoring and 3) nonphysiological positioning. The authors recognize that although detrusor and abdominal leak point pressures are increasingly being used in clinical practice, further standardization of the technical aspects of each is necessary. Alan J. Wein, M.D. Leak-Point Pressure: Clinical Application of Values at two Different Volumes M. T. MCLENNAN, C. F. MELICK

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A. E. BENT, Greater Baltimore Medical Center, Baltimore, Maryland

Int Urogynecol J, 11: 136 –141, 2000 A prospective analysis of 306 consecutive patients with genuine stress incontinence was performed to evaluate the clinical usefulness of additional leak-point pressure (LPP) determination at 200 ml. LPP values at both volumes were compared to maximal urethral closure pressure (MUCP) in an attempt to determine a critical cut-off value for the detection of a low MUCP (聿20 cmH2O). A positive LPP at 150 ml was found in 157 patients. The mean LPP for patients with a low MUCP was 58.5 cmH2O compared to 71.6 for those with a normal MUCP, which was statistically significant (p ⫽ 0.01). The correlation coefficient between LPP and MUCP was 0.317. A negative LPP was found in 30% (24/79) of the total having a low MUCP. The addition of values for LPP at 200 ml resulted in an increase in the number who leaked to 191, a 50% increase in the detection rate of low MUCP and a statistically significant relationship between LPP 聿60 cmH2O and low MUCP. Various critical cut-off values for LPP demonstrated good specificity but poor sensitivity for the detection of a low MUCP. It was concluded that there was a statistically significant relationship between LPP and MUCP. Performing LPP at 200 ml provides additional clinically useful diagnostic information. Editorial Comment: The point, of course, is not how the 2 parameters compare to one another but which proves to be the most accurate descriptor of outlet function with increases in intravesical pressure produced by exertion. Urologists favor the Valsalva leak point pressure, and gynecologists seem to favor the urethral pressure profile in one form or another. Alan J. Wein, M.D. M3 Muscarinic Receptors but not M2 Mediate Contraction of the Porcine Detrusor Muscle in Vitro D. J. SELLERS, T. YAMANISHI, C. R. CHAPPLE, C. COULDWELL, K. YASUDA AND R. CHESS-WILLIAMS, Department of Biomedical Science, University of Sheffield and Department of Urology, Royal Hallamshire Hospital, Sheffield, United Kingdom, and Department of Urology, Dokkyo University, Koshigaya Hospital, Koshigaya, Japan J Auton Pharmacol, 20: 171–176, 2000 1 The objective of the study was to determine the role of muscarinic receptor subtypes in mediating contraction of the porcine detrusor smooth muscle in vitro. 2 Strips of pig detrusor muscle were set up in physiological salt solution and the tensions developed by the

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tissues were recorded. Responses to carbachol were obtained in the absence and presence of a range of muscarinic antagonists (4-DAMP, methoctramine, darifenacin, oxybutynin, tolterodine and pirenzepine). Antagonist affinity values (pKB values) were calculated and compared with those quoted in the literature for these antagonists at each of the muscarinic receptor subtypes. 3 The M3-selective antagonists, 4-DAMP and darifenacin had high affinities (pKB values of 9.4 and 8.6, respectively). Oxybutynin, tolterodine and pirenzepine had affinities of 8.2, 8.1 and 6.8, respectively, whilst the M2-selective agent methoctramine had a relatively low affinity (pKB ⫽ 6.1). The rank order of affinities was, therefore, 4-DAMP ⬎ darifenacin ⬎ oxybutynin ⬎ tolterodine ⬎ pirenzepine ⬎ methoctramine for the pig detrusor. Correlation of the antagonist affinities obtained on the bladder with those published for these antagonists at the five muscarinic receptor subtypes identified the M3(m3)-receptor as the muscarinic subtype mediating detrusor contractile responses in vitro. 4 These data suggest that a small population of M3-muscarinic receptors must mediate direct contractile responses of the pig detrusor muscle to muscarinic receptor stimulation in vitro. Editorial Comment: There would not have been much interest in this article 10 years ago. Presently, pharmaceutical companies are quite interested in the problem of urinary incontinence due to overactive bladder, and there has been much dialogue on the value of receptor selectivity and tissue selectivity. Although the M2 receptor makes up the predominant percentage of muscarinic receptors in the pig bladder, M3 receptors are responsible for mediation of contractile responses of normal pig detrusor muscle to muscarinic stimulation in vitro. Evidence would suggest that the same situation exists in humans as well. M2 receptors are hypothesized to participate in the response of detrusor contraction to muscarinic stimulation under some pathological circumstances, and their participation during normal circumstances is also not excluded entirely. The ubiquitous nature of M3 receptors, which do not seem to be materially different in one organ than another, has made this concept of simple receptor selectivity less attractive than it might be otherwise because of the side effects that are inevitable with a blocker that is M3 selective but not tissue selective. If more than 1 muscarinic receptor is involved in the response of detrusor contraction to parasympathetic stimulation, especially in abnormal states, a less rather than more specific muscarinic antagonist may actually be an advantage as long as there is reasonable efficacy at M3 receptor sites. The Holy Grail of drug therapy directed against acetylcholine induced bladder overactivity would seem to be either an M3 receptor that is specific for detrusor smooth muscle or a degree of tissue specificity for a given antagonist. A potential pharmacological mechanism for the latter phenomenon would certainly be of extreme importance for all pharmaceutical houses interested in drug therapy for the overactive bladder. Alan J. Wein, M.D. Oxybutynin for Detrusor Instability With Adjuvant Salivary Stimulant Pastilles to Improve Compliance: Results of a Multicentre, Randomized Controlled Trial D. G. TINCELLO, E. J. ADAMS, J. R. SUTHERST AND D. H. RICHMOND, University Department of Obstetrics & Gynaecology, and Urogynaecology Department, Liverpool Women’s Hospital, Liverpool, United Kingdom BJU Int, 85: 416 – 420, 2000 Objective To test the hypothesis that compliance with oxybutynin would be improved if the severity of dry mouth could be reduced, thus leading to improved urinary symptom response and improved outcome, in a randomized, controlled trial of oxybutynin with or without salivary stimulant pastilles in patients with detrusor instability. Patients and methods Sixty-seven women with detrusor instability were randomized to a variable dose regimen of oxybutynin with (37) or without (30) salivary stimulant pastilles for 8 weeks. Patients were asked to complete a baseline voiding diary. In weeks 1 and 2, patients were encouraged to adjust the dose of oxybutynin themselves to achieve optimum symptomatic control. A second diary was completed in the sixth week and patients were reviewed at 8 weeks. The outcome measures were the compliance rate, followup attendance rate, maximum dose of medication, changes in voiding and incontinence episodes, and changes in severity of urgency and of dry mouth symptoms between the first and sixth week. Results Of the 67 women, 32 (47%) completed the study: the proportion completing was the same in both groups. Four patients had stopped the medication and there was no difference in the distribution of maximum dosage achieved between the groups. Both groups reported a reduced severity of urgency symptoms and increased severity of dry mouth. There were no differences in reported symptom change between the groups during the study. Conclusions The combination of oxybutynin and salivary stimulant pastilles does not improve compliance or symptom relief compared with oxybutynin alone: it does not allow a greater dose of oxybutynin to be tolerated. Editorial Comment: The active stimulatory agent in the pastilles was malic acid, buffered by calcium lactate and phosphate to protect the tooth surface from acidity. A pilot study published 3 years ago by most of these authors suggested a significant reduction in xerostomia with the

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ability of patients to tolerate higher doses of oxybutynin. This is another example of the fact that the results of randomized, placebo controlled trials often dull the optimistic sharp conclusions reached after pilot studies carried out by enthusiastic well-wishers. Alan J. Wein, M.D. Effect of Methoxamine on Maximum Urethral Pressure in Women With Genuine Stress Incontinence: A Placebo-Controlled, Double-Blind Crossover Study S. C. RADLEY, C. R. CHAPPLE, N. P. BRYAN, D. E. CLARKE AND D. A. CRAIG, Urology Research Department, Royal Hallamshire Hospital, Sheffield and Royston, United Kingdom, and Department of Pharmacology, Synaptic Pharmaceutical Corporation, Paramus, New Jersey Neurourol Urodynam, 20: 43–52, 2001 The aim of the study was to evaluate the potential role for a selective ␣1-adrenoceptor agonist in the treatment of urinary stress incontinence. A randomised, double-blind, placebo-controlled, crossover study design was employed. Half log incremental doses of intravenous methoxamine or placebo (saline) were administered to a group of women with genuine stress incontinence while measuring maximum urethral pressure (MUP), blood pressure, heart rate, and symptomatic side effects. Methoxamine evoked nonsignificant increases in MUP and diastolic blood pressure but caused a significant rise in systolic blood pressure and significant fall in heart rate at maximum dosage. Systemic side effects including piloerection, headache, and cold extremities were experienced in all subjects. The results indicate that the clinical usefulness of direct, peripherally acting sub-type-selective ␣1-adrenoceptor agonists in the medical treatment of stress incontinence may be limited by associated piloerection and cardiovascular side effects. Editorial Comment: One of the few uses of urethral profilometry for urologists is to measure the effects of drugs on the urethra. It is well-known that ␣ adrenergic stimulation causes contraction of bladder neck and proximal urethral smooth musculature, which generally translates into a change in urethral pressure profile. In this case methoxamine, an agent with more potent activity at ␣-1 than at ␣-2 adrenergic receptors, did not cause significant increases in maximum urethral profile pressure but caused a significant increase in the systolic blood pressure and a decrease in heart rate at maximum dosage. In addition, other ␣-1 systemic side effects were produced. The Holy Grail for those seeking to find a pharmacological solution for sphincteric incontinence is a medication which exerts a contractile effect on urethral smooth musculature without producing side effects, especially cardiovascular ones, or a medication which increases smooth and/or striated sphincter activity at a central level with the increased resistance either disappearing at the time of bladder contraction or being able to be overcome by a bladder contraction but at an acceptably low detrusor pressure. ␣ Agonist therapy, at least at this point in time, seems an unlikely solution to this problem (see next article). It is interesting that, looking back on the history of the results of ␣ agonist therapy reported by various respected individuals for sphincteric incontinence, very favorable results seem to have ceased at just about the time double-blind placebo studies became commonplace. Alan J. Wein, M.D. Phenylpropanolamine and the Risk of Hemorrhagic Stroke W. N. KERNAN, C. M. VISCOLI, L. M. BRASS, J. P. BRODERICK, T. BROTT, E. FELDMANN, L. B. MORGENSTERN, J. L. WILTERDINK AND R. I. HORWITZ, Departments of Internal Medicine, Neurology, and Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, Department of Neurology, Mayo Clinic, Jacksonville, Florida, Department of Neurology, Brown University School of Medicine, Providence, Rhode Island, and Department of Neurology and School of Public Health, University of Texas, Houston N Engl J Med, 343: 1826 –1832, 2000 Background Phenylpropanolamine is commonly found in appetite suppressants and cough or cold remedies. Case reports have linked the use of products containing phenylpropanolamine to hemorrhagic stroke, often after the first use of these products. To study the association, we designed a case-control study. Methods Men and women 18 to 49 years of age were recruited from 43 U.S. hospitals. Eligibility criteria included the occurrence of a subarachnoid or intracerebral hemorrhage within 30 days before enrollment and the absence of a previously diagnosed brain lesion. Random-digit dialing identified two matched control subjects per patient. Results There were 702 patients and 1376 control subjects. For women, the adjusted odds ratio was 16.58 (95 percent confidence interval, 1.51 to 182.21; P ⫽ 0.02) for the association between the use of appetite suppressants containing phenylpropanolamine and the risk of a hemorrhagic stroke and 3.13 (95 percent confidence interval, 0.86 to 11.46; P ⫽ 0.08) for the association with the first use of a product containing phenylpropanolamine. All first uses of phenylpropanolamine involved cough or cold remedies. For men and women combined, the adjusted odds ratio was 1.49 (95 percent confidence interval, 0.84 to 2.64; P ⫽ 0.17) for the association between the use of a product containing phenylpropanolamine and the risk of a

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hemorrhagic stroke, 1.23 (95 percent confidence interval, 0.68 to 2.24; P ⫽ 0.49) for the association with the use of cough or cold remedies that contained phenylpropanolamine, and 15.92 (95 percent confidence interval, 1.38 to 184.13; P ⫽ 0.03) for the association with the use of appetite suppressants that contained phenylpropanolamine. An analysis in men showed no increased risk of a hemorrhagic stroke in association with the use of cough or cold remedies containing phenylpropanolamine. No men reported the use of appetite suppressants. Conclusions The results suggest that phenylpropanolamine in appetite suppressants, and possibly in cough and cold remedies, is an independent risk factor for hemorrhagic stroke in women. Editorial Comment: By now I think everyone has seen or heard of this article. Combined with the relatively low efficacy of nonselective ␣ adrenergic agonists in the treatment of sphincteric incontinence, I think that this article effectively puts a lid, at least for now, on the use of such agents for the treatment of sphincteric incontinence not only in women, but probably in men as well, although phenylpropanolamine was reported not to be associated with increased risk of stroke in men. In commenting on this article, Abramowicz and Zucotti noted that no case control studies were available on the safety of phenylephrine, ephedrine or pseudoephedrine but that case reports have associated ephedra alkaloids with hypertension, stroke, seizures and death.1 They concluded, “phenylpropanolamine may not be the only alpha adrenergic agonist that can cause serious adverse effects when taken systemically in over the counter products marketed for nasal congestion or weight loss.” Alan J. Wein, M.D. 1. Phenylpropanolamine and other OTC alpha-adrenergic agonists. Med Lett Drugs Ther, 42: 113, 2000

Terazosin for Vesicosphincter Dyssynergia in Spinal Cord-Injured Male Patients J. K. BENNETT, J. FOOTE, T. R. EL-LEITHY, M. D. SALEEM, B. GREEN, C. L. ARCHER AND M. GRAY, Department of Surgery and Division of Urology, Emory School of Medicine and Shepherd Center, Department of Obstetrics and Gynecology, Morehouse School of Medicine and Midtown Urology, Atlanta, Georgia, Department of Urology, Theodor Bilharz Research Institute, Cairo and Department of Urology, Janoubwadi University, Sohag, Egypt, and Department of Urology, University of Virginia, Charlottesville, Virginia Mol Urol, 4: 415, 2000 Purpose: Evaluation of the role of the long-acting alpha-adrenergic blocker, terazosin, in the treatment of vesicosphincter dyssynergia (VSD) in spinal cord-injured male patients. Patients and Methods: Sixty spinal cord-injured male patients with VSD were recruited prospectively. Their mean age was 37 years (range 15–70 years). Baseline evaluation included a thorough medical history, clinical examination, blood pressure measurement, intravenous urogram, and videourodynamics. The patients received terazosin for a 90-day period. Videourodynamic evaluation after completion of the study included cystometrogram, sphincter electromyography, maximum urethral pressure gradient (MUPG), and measurement of post voiding residual (PVR) urine volume. The findings were compared with the pretreatment values. Results: Of the 60 patients, 35 completed the study. According to response to treatment, two groups were identified: Group A ⫽ responders (N ⫽ 17; 49%) and Group B ⫽ nonresponders (N ⫽ 18, 51%). In Group A, there was a significant decrease in the maximum detrusor pressure, from a mean of 105.3 to 73.9 cm H2O, and in MUPG, from a mean of 84.7 to 54.1 cm H2O. The bladder capacity and PVR did not change significantly in either group. The time since injury was significantly longer in Group A than in Group B. Conclusions: Terazosin in a dose of 10 mg/day was well tolerated and effective in reducing bladder outlet obstruction in many spinal cord-injured patients, as reflected by a decrease in maximum detrusor pressure and MUPG in 49% of the patients. Patients with a weak or negative response initially may respond later. Terazosin should be considered a first-line treatment of VSD prior to contemplating surgery. Editorial Comment: Another reason for using terazosin is prophylaxis against clinical manifestations of autonomic hyperreflexia in patients with lesions above T-7.1 Alan J. Wein, M.D. 1. Chancellor, M. B., Erhard, J. M., Hirsch, I. H. et al: Prospective evaluation of terazosin for the treatment of autonomic dysreflexia. J Urol, 151: 111, 1994

Desensitization of Bladder Sensory Fibers by Intravesical Resiniferatoxin, a Capsaicin Analog: Long-Term Results for the Treatment of Detrusor Hyperreflexia C. SILVA, M.-E. RIO AND F. CRUZ, Departments of Urology and Neurology, Hospital S. Joa¯o and Institute of Histology and Embryology of the Faculty of Medicine and IBMC of the University of Porto, Porto, Portugal Eur Urol, 38: 444 – 452, 2000 Objectives: To assess the pungency and the desensitizing effects of intravesical resiniferatoxin, an ultrapotent capsaicin analog, in patients with detrusor hyperreflexia. Methods: Fourteen patients with detrusor hyperreflexia were instilled during 30 min, without any form of local anesthesia, with 100 ml (or the bladder capacity if lower than that volume) of 50 or 100 nM

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resiniferatoxin solutions in 10% alcohol in saline. Patients were evaluated by voiding chart and urodynamic tests (volume to first contraction, maximal cystometric capacity, maximal detrusor pressure, icewater test) at 14, 30, 60, and 90 days and every 3 months thereafter. Results: Resiniferatoxin instillation did not evoke pain or temporary worsening of urinary symptoms. Treatment improved or abolished incontinence in 9 out of 12 incontinent patients. Mean urinary frequency decreased from 14.2 ⫾ 6.4 to 10.3 ⫾ 3.2 at 3 months (p ⫽ 0.01). At this time point, mean maximal cystometric capacity increased from 182.3 ⫾ 119.8 to 330.0 ⫾ 201.6 ml (p ⫽ 0.01) and the ice water test, positive in 13 cases, became negative in 8 of them. Maximal detrusor pressure was not modified by the treatment. The effect was long-lasting, reaching 12 months in 7 cases. Conclusions: The absence of irritative symptoms during bladder instillation of resiniferatoxin and the rapid onset of desensitization make this vanilloid superior to capsaicin for the treatment of detrusor hyperreflexia. Editorial Comment: There is little question that resiniferatoxin has advantages over capsaicin as an intravesical agent for the desensitization of bladder afferent C fibers. A significant question yet to be answered is whether the vanilloid desensitizers would exhibit efficacy for types of bladder activity other than those subserved by C afferent fibers and for pain. Alan J. Wein, M.D. Role of Dopamine D1 and D2 Receptors in the Micturition Reflex in Conscious Rats S. SEKI, Y. IGAWA, K. KAIDOH, O. ISHIZUKA, O. NISHIZAWA AND K.-E. ANDERSSON, Department of Urology, Shinshu University School of Medicine, Matsumoto, Japan, and Department of Clinical Pharmacology, Lund University Hospital, Lund, Sweden Neurourol Urodyn, 20: 105–113, 2001 To clarify the role of dopamine D1 and D2 receptors in the volume-induced micturition reflex, conscious, female rats were investigated cystometrically before and after intravenous administration of SKF 38393 (a selective D1 receptor agonist). SCH 23390 (a selective D1 receptor antagonist), quinpirole (a selective D2 receptor agonist), and remoxipride (a selective D2 receptor antagonist). The effect of quinpirole was also investigated in the presence of remoxipride. Intravenous administration of SKF 38393 (0.01–3.0 mg/kg) did not affect any cystometric parameters investigated. On the other hand, SCH 23390 (0.1–1.0 mg/kg i.v.) reduced bladder capacity and micturition volumes and increased the micturition pressure in a dosedependent manner. Quinpirole (0.01– 0.1 mg/kg) given intravenously, dose-dependently decreased bladder capacity and micturition volumes. Pre-treatment with remoxipride (1.0 mg/kg i.v.) significantly attenuated the effect of quinpirole (0.1 mg/kg i.v.). Remoxipride (0.1–1.0 mg i.v.) itself did not cause any significant changes in the cystometric parameters. These results suggest that in conscious rats, D1 receptors tonically inhibit the micturition reflex and that D2 receptors are involved in facilitation of the micturition reflex. It may be speculated that detrusor hyperreflexia associated with Parkinson’s disease results from activation failure of D1 receptors and that administration of D2 receptor agonists might worsen the condition. Editorial Comment: There may be 2 types of dopaminergic mechanisms involved in cerebral induced bladder overactivity: 1) activation failure of D1 receptors (perhaps by a relative deficiency of dopamine in this area, such as exists in Parkinson’s disease) and 2) overactivation of D2 receptors (as demonstrated in cerebral infarcted rats by Yokoyama et al1). As the authors suggest, further insights into the actions of inhibitory D1 and excitatory D2 receptors on the micturition reflex may lead to new pharmacological treatments of bladder overactivity. Alan J. Wein, M.D. 1. Yokoyama, O., Yoshiyama, M., Namiki, M. et al: Glutaminergic and dopaminergic contributions to rat bladder hyperactivity after cerebral artery occlusion. Am J Physiol, 276: R935, 1999

The Etiology of Urinary Retention After Surgery for Genuine Stress Incontinence M. P. FITZGERALD AND L. BRUBAKER, Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois Neurourol Urodyn, 20: 13–21, 2001 Transient postoperative urinary retention after stress incontinence surgery is common, and there is no widely accepted method of hastening the return to normal voiding. The etiology of this retention is poorly understood. Failure of the relaxation of the striated external urethral sphincter has been proposed as an etiologic agent, but has not been documented. Ten patients about to undergo a Burch colposuspension or sub-urethral sling, who demonstrated normal preoperative voiding, were recruited to a study of postoperative retention. Hook-wire electromyographic (EMG) probes were placed into the external urethral sphincter while the patients were under anesthesia, and a suprapubic catheter was placed. We performed instrumented voiding trials 1 or 2 days after surgery while continuously recording urethral EMG and intravesical pressure. Two patients demonstrated normal voiding. Two patients were able to void but demonstrated no EMG silencing. Six patients were unable to void and demonstrated persistent EMG activity. Four of these demonstrated no detrusor contraction, whereas two demonstrated detrusor contrac-

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tions. All patients resumed normal voiding by clinical parameters within 14 days of surgery. Our study supports other research that suggests that failure of relaxation of the striated urethral sphincter contributes to postoperative urinary retention. Editorial Comment: Incomplete relaxation of the striated sphincter may indeed provide an explanation or contributing factor for some cases of urinary retention after surgery. Action could be 2-fold: 1) by creating an obstruction which a detrusor contraction could not overcome and 2) by inhibition of the micturition reflex via sensory fibers emanating from the striated sphincter itself. ␣ Adrenergic antagonists may favorably affect this pathology by a spinal cord action on striated sphincter activity and an action on the parasympathetic ganglia to facilitate the reflex. Potential contributory factors to postoperative retention include 1) traumatic instrumentation, 2) bladder over distention, 3) diminished awareness of bladder sensation, 4) decreased bladder contractility, 5) increased outlet resistance, 6) decreased micturition reflex activity, 7) nociceptive inhibitory reflex and 8) preexistent outlet pathology. Alan J. Wein, M.D. Long-Term Effectiveness of Sacral Nerve Stimulation for Refractory Urge Incontinence R. A. JANKNEGT, M. M. HASSOUNA, S. W. SIEGEL, R. A. SCHMIDT, J. B. GAJEWSKI, D. A. RIVAS, M. M. ELHILALI, ` NY¨ EHOLT, M. FALL, U. JONAS, D. C. MILAM, P. E. V. VAN KERREBROECK, H. E. DIJKEMA, A. A. B. LYCKLAMA A F. CATANZARO, C. J. FOWLER AND K. A. OLESON, Academisch Ziekenhuis Maastricht, Maastricht, Academisch Ziekenhujs, Nijmegen, Twenteborg Ziekenhuis Almelo, Almelo and Academisch Ziekenhuis Leiden, Leiden, The Netherlands, Toronto Hospital Western Division, Toronto, Ontario, Queen Elizabeth II Health Sciences Center—NHI, Halifax, Nova Scotia and Royal Victoria Hospital, Montreal, Quebec, Canada, Metropolitan Urologic Specialists, St. Paul, Minnesota, University of Colorado Health Sciences Center, Denver, Colorado, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, Vanderbilt University, Nashville, Tennessee, Sahlgrenska University Hospital, Göteborg, Sweden, Medizinische Hochschule, Hannover, Germany, Policlinico Multimedica, Milan, Italy, National Hospital for Neurology and Neurosurgery, London, United Kingdom, and Medtronic Inc., Minneapolis, Minnesota Eur Urol, 39: 101–106, 2001 OBJECTIVES: To evaluate the long-term efficacy of sacral nerve stimulation for refractory urinary urge incontinence. STUDY DESIGN AND METHODS: Urge incontinent patients qualified for surgical implantation of a neurostimulator system after trial screening with percutaneous test stimulation. Surgical implantation of the InterStim System (Medtronic Inc., Minneapolis, Minn., USA) was performed in cases where a ⬎50% reduction in incontinence symptoms was documented during the 3- to 7-day test stimulation period. The InterStim System consists of an implantable pulse generator, a transforamenally placed quadripolar lead, and an extension that connects these two devices for unilateral stimulation of the S3 or S4 sacral nerve. Efficacy for 96 implanted patients was based on urinary symptom changes as quantified in voiding diaries collected at baseline and annually after surgical implantation. RESULTS: As compared to baseline, the group of 96 implanted patients demonstrated significant reductions in urge incontinent symptoms at an average of 30.8 ⫹/⫺ 14.8 (range 12– 60) months with respect to the number of urge incontinent episodes per day, severity of leaking, and the number of absorbent pads/diapers replaced per day due to incontinence (all p⬍0.0001, respectively). Gender, pretreatment variables, and age were not found to be relevant factors that affected these results. 11 of the 96 patients underwent device explant due to lack of efficacy, pain or bowel dysfunction. These data were conservatively included in the efficacy results. No permanent injuries associated with the devices or therapy were reported. CONCLUSION: Sacral nerve stimulation is an effective treatment for refractory urge incontinence with sustained long-term benefit through an average of 30.8 months. Sacral Neuromodulation for Women With Fowler’s Syndrome M. J. SWINN, N. D. KITCHEN, R. J. GOODWIN AND C. J. FOWLER, Departments of Uroneurology and Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom Eur Urol, 38: 439 – 443, 2000 Neuromodulation of the sacral nerves has been found to be an effective therapy for a variety of lower urinary tract dysfunctions. The reported success rate for the period of trial stimulation (peripheral nerve evaluation test) prior to permanent implantation of a sacral nerve stimulator is variable, but generally reported to be in the region of 30 –50%. We present here the results of the peripheral nerve evaluation test in 38 patients with urinary retention. 34 of the 38 had been found to have an abnormality of their striated urethral sphincter on electromyography using a concentric needle electrode, i.e., they had the disorder which was described by Fowler and coworkers in 1988. The overall success rate in this group was 68%. We believe that our relatively high success rate is due to sacral neuromodulation working via a mechanism which involves the urethral sphincter, an abnormality which had been demonstrated in 89% of these patients. Twelve of the patients subsequently underwent permanent implantation of a sacral nerve stim-

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ulator, and all of them have experienced a return of voiding. However, in 2 patients, there is a persisting need for self-catherization. There is, however, a high reoperation rate. Editorial Comment: This is pretty amazing stuff. Sacral neuromodulation is now an accepted treatment alternative for refractory urge incontinence and idiopathic urinary retention. Those interested and potentially interested in the technique should certainly read these articles and the supporting literature. It should be noted, however, that Janknegt et al report that a third of patients required surgical revision to resolve an adverse event and in their study of 96 patients with implants, 11 implants were removed due to lack of efficacy (9), chronic leg pain (1) and bowel dysfunction (1). In the study by Swinn et al 5 of 12 patients who underwent a permanent implant required a total of 8 reoperations for pain at the site of implant (3), slippage of the sacral lead (4) and infection that required stimulator removal (1). Those who regard this particular glass as half empty will be properly critical of the surgical complications. Those who regard it as half full will recall the early days of the inflatable penile prosthesis and artificial genitourinary sphincter, both of which experienced continuing multiple technical difficulties with subsequent resolution because of improvements in materials and technique. Alan J. Wein, M.D. Non-invasive Antidromic Neurostimulation: A Simple Effective Method for Improving Bladder Storage I. K. WALSH, T. THOMPSON, W. G. G. LOUGHRIDGE, S. R. JOHNSTON, P. F. KEANE AND A. R. STONE, Department of Urology, University of California, Davis, Sacramento, California, and Department of Urology, Belfast City Hospital, Belfast, Northern Ireland, United Kingdom Patients with intractably diminished bladder storage function are encountered frequently by neurourologists, occasionally requiring reconstructive surgery for appropriate resolution. Although sacral neuromodulation is a recognized effective therapeutic modality, present techniques are technically demanding, invasive, and expensive. This study investigated the effect of non-invasive third sacral nerve (S3) stimulation on bladder activity during filling cystometry. One hundred forty-six patients underwent standard urodynamic filling cystometry that was then immediately repeated. Patients in the study group (n ⫽ 74) received antidromic transcutaneous sacral neurostimulation during the second fill and the control group (n ⫽ 72) underwent a second fill without neurostimulation. A statistically significant increase in bladder storage capacity without a corresponding rise in detrusor pressure was observed in the neurostimulated patients. This improvement in functional capacity is an encouraging finding that further supports the use of this non-invasive treatment modality in clinical practice. Editorial Comment: This is promising work and another potential application of neural modulation. The question is, can this be applied to a system that will provide reliable day-to-day stimulation with improvement in clinical parameters? Alan J. Wein, M.D. Comparative Study of the Effects of Magnetic Versus Electrical Stimulation on Inhibition of Detrusor Overactivity T. YAMANISHI, R. SAKAKIBARA, T. UCHIYAMA, S. SUDA, T. HATTORI, H. ITO AND K. YASUDA, Departments of Urology and Neurology, Chiba University School of Medicine, Chiba and Department of Urology, Dokkyo University School of Medicine, Koshigaya Hospital, Saitama, Japan Urology, 56: 777–781, 2000 Objectives. To perform a randomized comparative study investigating the urodynamic effects of functional magnetic stimulation (FMS) and functional electrical stimulation (FES) on the inhibition of detrusor overactivity. Methods. Thirty-two patients with urinary incontinence due to detrusor overactivity (15 men, 17 women; age 62.3 ⫾ 16.6 years) were randomly assigned to two treatment groups (15 patients in the FMS group and 17 in the FES group). Stimulation was applied continuously at 10 Hz in both groups. For FMS, the magnetic stimulator unit was set on an armchair type seat and had a concave-shaped coil, so that the patients could sit during stimulation. For FES, a vaginal electrode was used in the women and a surface electrode on the dorsal part of the penis was used in the men. Cystometry was performed before and during the stimulation. Results. The bladder capacity at the first desire to void and the maximum cystometric capacity increased significantly during stimulation compared with prestimulation levels in both groups (P ⫽ 0.0054 and 0.0026, respectively, in the FMS group and P ⫽ 0.0015 and 0.0229, respectively, in the FES group). However, the increase in the maximum cystometric capacity was significantly (P ⫽ 0.0135) greater in the FMS group (114.2 ⫾ 124.1 mL or an increase of 105.5% ⫾ 130.4% compared with the pretreatment level) than that in the FES group (32.3 ⫾ 56.6 mL or an increase of 16.3% ⫾ 33.9%). Detrusor overactivity was abolished in 3 patients in the FMS group but not in any patient in the FES group. Conclusions. Although both treatments were effective, the inhibition of detrusor overactivity appeared greater in the FMS group than in the FES group.

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Editorial Comment: This was a subacute study with a second cystometry started 5 minutes after initiation of the electrical or magnetic stimulation and, thus, was carried out during the stimulation. Bladder capacity at first desire to void increased from 140.9 to 225.1 ml. in the functional magnetic stimulation group and from 152.7 to 220.4 ml. in the functional electrical stimulation group. Corresponding numbers for maximum cystometric capacity were 176.3 to 290.5 ml. in the functional magnetic stimulation group and 234.6 to 266.9 ml. in the functional electrical stimulation group. There was no sham group. Whether these results are translatable into a chronic favorable effect after multiple outpatient stimulation sessions is unknown. The authors state that for functional electrical stimulation it would be necessary to stimulate twice daily or every other day for 4 to 6 weeks to reach a significant improvement or cure. Since the device is portable this could be done at home. For functional magnetic stimulation the authors report that, in their opinion, stimulation twice weekly for 5 to 6 weeks would be necessary to achieve similar results. As the magnetic device is presently configured, it would be necessary to perform functional magnetic stimulation in an office. These results of the noninvasive electrical and magnetic treatment of overactive bladder need to be translated into long-term clinical results with long-term sham control studies that evaluate symptoms, quality of life and ease of use. The urodynamic parameters, although interesting, would be of less interest if one were evaluating these parameters as seen from the standpoint of the patient. The results are encouraging for peripheral electrical stimulation and magnetic stimulation as treatment for overactive bladder. Alan J. Wein, M.D. Vulvodynia: An Introduction and Critical Review of a Chronic Pain Condition R. M. MASHEB, J. M. NASH, E. BRONDOLO AND R. D. KERNS, Yale Psychiatric Institute, Yale University School of Medicine, New Haven and Psychology Service, Veterans Administration Connecticut Healthcare System, West Haven, Connecticut, The Miriam Hospital, Brown University School of Medicine, Providence, Rhode Island, and Department of Psychology, St. John’s University, Jamaica, New York Pain, 86: 3–10, 2000 Permission to Publish Abstract Not Granted Editorial Comment: This is a difficult to diagnose and treat condition which may be confused with interstitial cystitis. The authors describe 5 subtypes of vulvodynia. They classify the vulvar vestibulitis syndrome as the last subtype, characterized by discomfort and hypersensitivity in the vulvar vestibule in the absence of physical findings except for varying degrees of erythema. The vulvar vestibulitis syndrome seems to be the most common subtype and the others include 1) vulvar dermatoses, 2) cyclic candidiasis/vulvitis, 3) vulvar papillomatosis and 4) essential vulvodynia (except for erythema, I have trouble distinguishing the descriptions of this from the vulvar vestibulitis syndrome). The standard criteria for the vulvar vestibulitis syndrome are 1) severe pain on vestibular touch or attempted vaginal entry, 2) tenderness to pressure localized within the vulvar vestibule, 3) no evidence of physical findings except for varying degrees of erythema and 4) symptoms of at least 6 months in duration of moderate to severe intensity. As with interstitial cystitis, prevalence is uncertain and has been quoted to be as few as 200,000 women in the United States or as many as 15% of women who seek private practice gynecological care! Current theories of etiology include 4 major categories of 1) candida, 2) neurological, 3) hormonal and 4) allergy. Affected women are predominantly white with onset in the mid 20s. Risk factors appear to be early oral contraceptive use, early menses and early first sexual experience. Therapy includes 1) systemic and topical treatments—rather vague (amitriptyline, low oxalate diet with oral calcium citrate to decrease urinary oxalate concentration, 2) surgeries and injections (vestibulectomy with vaginal advancement, ␣ interferon injections) and 3) biofeedback of the pelvic floor musculature (these results seem as good as any). As urologists we must keep this diagnosis in mind when evaluating patients referred to us for “interstitial cystitis.” Alan J. Wein, M.D. Usefulness of Urodynamic Examination in Female Urinary Incontinence—Lessons From a Population-Based, Randomized, Controlled Study of Conservative Treatment K. HOLTEDAHL, M. VERELST, A. SCHIEFLOE AND S. HUNSKAAR, Institute of Community Medicine, University of Tromsø, and Department of Gynecology and Obstetrics, University Hospital, Tromsø, Department of Gynecology and Obstetrics, Central Hospital, Bodø, and Department of Public Health and Primary Care, University of Bergen, Bergen, Norway Scand J Urol Nephrol, 34: 169 –174, 2000 Objective: To test the usefulness of urodynamic examination in female urinary incontinence. Material and Methods: As part of a population-based, randomized, controlled treatment study in general practice, the

VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY

control group was offered urodynamic examination before and after delayed treatment starting 6 months after inclusion in the study, i.e. after the first outcome evaluation comparing the initially treated group with the control group. The intervention group was offered urodynamic examination only after the final outcome evaluation at 12 months. Eighty-seven women, aged 50 –74, from three Norwegian municipalities participated. Results: There was no difference in treatment outcome whether the patients had urodynamic examination or not. Eleven patients (26% of 42 control patients) had their diagnosis revised after urodynamic examination, ten of them with a subsequent change in treatment. The outcome for this group was no different than for the other patients. As a subgroup, the 11 patients had more severe leakage (p ⫽ 0.048) and more previous gynecological operations (p ⫽ 0.038) than the other control group patients. Conclusions: Our study supports the idea that in general practice, or in rather unselected patients, women with urinary incontinence may be classified and treated without urodynamic examination. If there is little or no improvement during the first few months referral should be considered, and this should be done sooner for patients with severe incontinence or prior gynecological operations than for other patients. Editorial Comment: The implications of this article agree with 2 of my personal prejudices. The first is that conservative noninvasive therapy can be instituted in most women with a complaint of urinary incontinence and with no findings or symptoms suggestive of a more serious abnormality (for example hematuria, pain, poor emptying) without an extensive evaluation. The improvement achieved may be enough to satisfy the patient and, of course, no further therapy or evaluation would be necessary. The second implication relates to evaluation of such patients by primary care providers. When I talk to such groups I provide them with my “laundry list” of findings and conditions that in my opinion should prompt specialist referral. Many patients will have no checks on this list and for those I endorse the concept of a simple algorithmic approach to evaluation and initiation of conservative noninvasive management by primary care practitioners with specialist referral for treatment failure after a 6 to 8-week trial. Although some of my colleagues might disagree, I think this is good medicine and sound economics. Alan J. Wein, M.D. Failure of Allograft Suburethral Slings M. P. FITZGERALD, J. MOLLENHAUER AND L. BRUBAKER, Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, and Department of Biochemistry, Rush-PresbyterianSt. Luke’s Medical Center, Chicago, Illinois BJU Int, 84: 785–788, 1999 Objectives To report our experience of using freeze-dried irradiated fascia lata allografts for suburethral sling procedures. Patients and methods Between December 1996 and September 1998, 35 patients (mean age 60.25 years, range 37–79) underwent suburethral sling placement with fascia allograft. These patients were reviewed, with the findings at the time of any surgical re-exploration. Eleven (31%) had undergone prior surgery for genuine stress incontinence and 32 (91%) had a preoperative diagnosis of intrinsic sphincter deficiency. Results On re-operation for persistent or recurrent stress incontinence, the allograft was present but grossly degenerated in two (6%) patients and completely absent in five (14%) patients. Histology of a retrieved graft fragment showed both fibroblast proliferation and degeneration within the graft. Conclusion The use of freeze-dried, irradiated fascia lata for suburethral sling procedures was associated with a material failure rate of 肁20%. We caution against its use in this setting. Functional Failure of Fascia Lata Allografts M. P. FITZGERALD, J. MOLLENHAUER, P. BITTERMAN AND L. BRUBAKER, Division of Urogynecology and Reconstructive Pelvic Surgery, and Departments of Biochemistry and Pathology, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois Am J Obstet Gynecol, 181: 1339 –1346, 1999 OBJECTIVES: Fascia lata allografts are commonly used in urogynecologic procedures. Functional failure of several grafts has occurred, and such failure has been recognized as a materials problem in 12 patients. STUDY DESIGN: Twelve patients with failure of an initial urogynecologic procedure performed with irradiated and freeze-dried donor fascia lata grafts underwent reoperation. Portions of the implanted fascia lata grafts could be retrieved in 7 cases. Graft specimens underwent histologic processing followed by hematoxylin and eosin staining. RESULTS: Histopathologic analyses of the retrieved material demonstrated several ongoing processes in the failed grafts. A few grafts showed areas of ideal remodeling. Most grafts, however, showed areas of disorganized remodeling and areas of graft degeneration. Evidence of immune reaction to the graft was observed in some cases. CONCLUSION: The high materials failure rate associated with the use of irradiated and freeze-dried donor fascia lata grafts suggests that such tissue should not be used for urogynecologic procedures.

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The Antigenicity of Fascia Lata Allografts M. P. FITZGERALD, J. MOLLENHAUER AND L. BRUBAKER, Department of Obstetrics/Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, and Department of Biochemistry, Rush-PresbyterianSt. Luke’s Medical Center, Chicago, Illinois BJU Int, 86: 826 – 828, 2000 Objective To determine whether commercially available fascia lata allograft material contains donor antigens. Materials and methods Human leukocyte antigens (HLA) class I and II were assessed in: (i) freeze-dried fascia lata allografts: (ii) a Tutoplast11 fascia lata graft (Mentor Urology, Santa Barbara, CA, USA); (iii) an acellular dermal graft; and (iv) a successful donor fascia sacrocolpopexy graft one year after implantation, using a polymerase chain reaction sequence-specific primer-based assay. Results The donor for both the freeze-dried fascia lata and Tutoplast fascia lata was fully HLA-typed. At one year after implantation, antigens from the implanted sacrocolpopexy graft matched the host blood antigens. The antigenicity of the acellular dermal graft could not be ascertained because this material interfered with the assay. Conclusion Donor fascia lata grafts prepared by freeze-drying or by the Tutoplast technique retain donor antigens. The significance of this antigenicity is unknown. All donor antigens are replaced by host antigens after implantation. Is Fascia Lata Allograft Material Trustworthy for Pubovaginal Sling Repair? D. S. ELLIOTT

AND

T. B. BOONE, Department of Urology, Mayo Clinic, Rochester, Minnesota

Urology, 56: 772–775, 2000 Objectives. In a recent publication, cadaveric fascia lata used for pubovaginal sling procedures was reported as having an early, rapid, and high failure rate. Recurrent incontinence was reported to occur from 1 week to 5 months after surgery. The study concluded that cadaveric tissue should not be used for urogynecologic procedures. Their results, however, were significantly different from what we found in clinical practice. We reviewed our series of cadaveric pubovaginal slings to determine the occurrence of rapid breakdown of cadaveric sling tissue leading to recurrent stress urinary incontinence. Methods. At our institution, since June 1998, pubovaginal slings have been performed using only cadaveric fascia lata. Because all of the failures in the aforementioned study occurred within 5 months (mean 11 weeks) of surgery, we included in our series only patients with a minimum of 12 months of follow-up to ensure a long enough follow-up period for failure of the donor tissue to occur. Duration of follow-up and current continence status was documented. Results. Twenty-six patients, with a mean follow-up of 15 months (range 12 to 20), were evaluated. Twenty-four of 26 (92%) patients used one or fewer pads per day: 20 of 26 (77%) were completely dry and 4 of 26 (15.4%) used only one pad per day. Two of 26 (7.7%) required two pads per day. Twenty-five of 26 (96%) reported being “significantly improved” and were “very pleased and satisfied” with the results of surgery. Conclusions. We found no evidence of rapid degradation of solvent-dehydrated cadaveric tissue resulting in early recurrent incontinence. We think these data support the continued use of cadaveric allograft material, especially given its intraoperative and postoperative advantages. Clearly, long-term evaluation of the durability of the cadaveric slings in comparison with autologous fascia is warranted. Gore-tex Patch Sling: 7 Years Later J. M. CHOE chussetts

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D. R. STASKIN, Division of Urology, Beth Israel Deaconess Medical Center, Boston, Massa-

Urology, 54: 641– 646, 1999 Objectives. To assess the long-term results of a transvaginal endoscopic Gore-Tex patch sling in women with genuine stress urinary incontinence due to urethral hypermobility and/or intrinsic sphincter deficiency, with or without coexistent urge incontinence. Methods. Between December 1989 and June 1994, we performed a Gore-Tex patch sling procedure in 141 consecutive women. All patients had documented stress urinary incontinence on preoperative videourodynamic testing. We conducted outcomes analysis using the information from postoperative office visits, detailed chart reviews, patient questionnaires, and telephone surveys. Results. A complete follow-up was available in 90 patients. The mean follow-up was 51 months (range 27 to 84). Their mean age was 54.2 years (range 32 to 86). Stress incontinence was completely cured in 80 (88.9%) of 90 patients. Pure stress incontinence persisted in 4 (4.4%) of 90 patients. Mixed incontinence occurred in 6 (6.7%) of 90 patients. Pure urge incontinence was experienced by 16 (17.8%) of 90 patients. Six patients required incision of the Gore-Tex patch for obstruction or retention; 3 remain continent. Five patients developed vaginal granulation tissue requiring Gore-Tex patch removal; 1 remains continent. There was no bladder or urethral erosion. Conclusions. The transvaginal Gore-Tex patch sling has provided durable efficacy with minimal morbid-

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ity for the treatment of stress urinary incontinence due to anatomic urethral hypermobility and/or intrinsic sphincter deficiency. Allograft Sling Material: Is it the State of the Art? G. M. GHONIEM, Tulane University Medical Center, New Orleans, Louisiana Int Urogynecol J, 11: 69 –70, 2000 No Abstract The Use of Cadaveric Fascia Lata in the Treatment of Stress Urinary Incontinence in Women A. K. SINGLA, Department of Urologic Surgery, University of Nebraska Medical Center, Omaha, Nebraska BJU Int, 85: 264 –269, 2000 No Abstract Editorial Comment: There are more and more articles in the literature purporting to show the advantages or disadvantages of the use of autologous rectus fascia or fascia lata, allograft fascia and synthetics for sling procedures. There is no unanimity of opinion, and individuals continue to use what works best for them. Fitzgerald et al, in 2 articles that seem to describe the same group of patients in slightly different fashions, caution against a high material failure rate using fascia lata allografts. They also report that fascia lata allografts remain antigenic after freezedrying and solvent treatment, although the clinical significance of this is unknown. Elliott and Boone reported no such difficulty using cadaveric fascia lata as sling material. The only possible difference in technique seems to be the use of polytetrafluoroethylene suture arms by Fitzgerald et al. Choe and Staskin report excellent results using synthetic polytetrafluoroethylene patches as sling material, but a significant problem with their study is that only 90 of 141 patients were able to be followed. Even so, of those 90 patients 6 required incision of the patch for obstruction or retention, and 5 required removal because of vaginal granulation tissue, although there was no bladder or urethral erosion. Ghoniem seems to believe that the use of allograft sling material simplifies the sling procedure from the standpoint of technique and morbidity without a decrement in success rates. Singla cautions that, although long-term results are still awaited, short-term results with autograft fascia lata are comparable to the efficacy, durability and success of autologous fascia lata. On the other hand, Blaivas, McGuire and others continue to use autologous fascia and report excellent results with minimal morbidity. Clearly, the final chapter has yet to be written. Alan J. Wein, M.D. The Promise of Tension-Free Vaginal Tape for Female SUI J. KLUTKE AND C. KLUTKE, Department of Obstetrics and Gynecology, Section of Urogynecology, University of Southern California Medical Center, Los Angeles, California, and Washington University Medical Center, St. Louis, Missouri Contemp Urol, 59 –73, October 2000 No Abstract Editorial Comment: Contemporary Urology continues to publish articles that have wonderful graphics, and this article is no exception. I would suggest that anyone interested in the treatment of sphincteric incontinence read this article for 2 reasons. First of all, it describes the Gynecare* TVT (tension-free vaginal tape) technique with extremely well-done illustrations. Secondly, the authors report their experience with collectively performing more than 600 of these procedures since November 1998. They report that they have encountered no major operative complications, have had to transfuse no one, have not had a problem with urinary tract infection and have not encountered vaginal healing complications related to the sling material. At 1-year followup they report an 86% cure rate for stress incontinence (this includes patients with low Valsalva leak point pressure and low urethral closure pressure) and an additional 10% “improvement” rate, although it is a bit difficult to know exactly what this means. If you currently perform this procedure or are interested in doing it, you should read this article. Alan J. Wein, M.D. Surgery for Female SUI: Perspectives and Controversies J. G. BLAIVAS, Weill Medical College of Cornell University, New York, New York Contemp Urol, 12–31, September 2000 No Abstract * Ethicon, Inc., Somerville, New Jersey.

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Surgery for Female SUI: Old Versus New J. G. BLAIVAS, Weill Medical College of Cornell University, New York, New York Contemp Urol, 79 – 87, November 2000 No Abstract Editorial Comment: This is a report of 2 roundtable discussions moderated by Blaivas (including Dmochowski, Klutke, Raz and Zimmern) on the variety of surgical procedures currently used to treat female sphincteric incontinence. You will be surprised (maybe not) to see that there was little unanimity regarding specifics having to do with even a “simple index case.” Perhaps the best part of the entire discussion was a well thought out summary statement made by Appell after reading all of this, and I think this statement is worth noting: “. . .these superstars in the field of female urology essentially all agree (as do I) that women suffering with stress incontinence have some degree of sphincteric incompetence. Additionally, they believe (as I do) that this is best treated by the placement of ‘something’ suburethrally, resulting in coaptation of the outlet without obstruction. After that, there are differing points of view regarding the best sling material, the sling’s exact placement, how the sling should be fixed in position, how much of the patient’s tissue should be disrupted during placement, and even how the patient’s urinary output is best managed postoperatively.” “All of these viewpoints are both correct and incorrect, depending on the individual patient’s findings, which include symptoms, previous treatments and results, pelvic exam (including evaluation of hypermobility of the vesicourethral junction), and urodynamic testing. I personally do not do the same operation in every patient, but use all of the procedures discussed by the panelists as well as some others. The selection depends on my evaluation of the individual patient and my experience with the varying procedures in each particular subset of patients . . . .” “This is the art of medicine at its best. We who work in this field on a daily basis keep trying to make science out of this art. I hope that, some day, it does become a science. At that point in time, we will truly have made some headway in the successful management of female stress incontinence. For now, we and our patients will have to be content with about an 80% to 85% success rate regardless of the surgeon and the specifics of the sling he or she chooses.” Alan J. Wein, M.D.

TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION CT Evaluation of Renovascular Disease A. KAWASHIMA, C. M. SANDLER, R. D. ERNST, E. P. TAMM, S. M. GOLDMAN AND E. K. FISHMAN, Departments of Radiology and Urology, University of Texas Medical School and Department of Radiology, Lyndon B. Johnson General Hospital, Houston, Texas, and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland Radiographics, 20: 1321–1340, 2000 Computed tomography (CT) plays an important role in evaluation and management of primary renovascular disease. Nonenhanced CT is useful for demonstrating renal hemorrhage, renal parenchymal or vascular calcifications, and masses. Contrast material-enhanced CT is essential to identify global or regional nephrographic abnormalities resulting from the vascular process (eg, renal infarcts, ischemia secondary to renal artery stenosis, arteriovenous communications). In addition, renal manifestations of a systemic disease (eg, vasculitis, thromboembolic disease) can be seen at CT. In trauma, occlusion of the main renal artery can be accurately diagnosed with contrast-enhanced CT. In cases of spontaneous renal hemorrhage without an apparent cause (eg, vasculitis, coagulopathy), a careful CT study should be performed to exclude renal cell carcinoma. The presence of fat in a hemorrhagic renal mass larger than 4 cm in diameter is characteristic of angiomyolipoma complicated by hemorrhage. Acute renal vein thrombosis appears as a clot in a distended renal vein, whereas renal vein retraction with collateral vessels is highly indicative of chronic thrombosis. Helical CT, especially with multiplanar two-dimensional and three-dimensional reconstruction following an intravenous injection of iodinated contrast material, has greatly improved our ability to directly image the proximal renal arteries and detect vascular lesions. Editorial Comment: In this report on CT evaluation of all aspects of renovascular disease the authors include exceptionally illustrative images and describe in detail relevant pathological findings and contemporary management. The discussions and illustrations related to traumatic renal injury are superb and accurate. The ability of CT to detect renal arterial injury is emphasized since the early vascular phase of a contrast spiral CT can delineate clearly the exact