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ABSTRACT: We evaluated the result of periurethral collagen injection in incontinent patients after prior urethral surgery.
We reviewed the charts of patients who underwent periurethral collagen injection between January 2000 and December 2006 for persistent stress urinary incontinence after a failed suspension procedure or urethral repair. Preoperative assessment included the validated Urogenital Distress Inventory-6 symptom questionnaire, a single global quality of life score, history and physical examination, cystogram while standing and multichannel urodynamics. All patients had a well supported urethra and intrinsic sphincteric deficiency. Outcome measures included questionnaires and 3-dimensional urethral ultrasound at 6 weeks, 6 to 12 months and yearly thereafter. In patients who were still symptomatic after the first injection a repeat injection was considered when there was asymmetrical or low collagen volume on ultrasound, and another therapy was considered when ultrasound findings were adequate.
In 31 consecutive patients Urogenital Distress Inventory-6 question 3 and quality of life scores decreased after collagen injection (mean volume 5.5 cc). Baseline postoperative collagen volume on ultrasound was 2.6 cc (range 0.8 of 4.8). Of the patients 93% considered themselves clinically improved or cured, 17 of 31 required only 1 injection with a symmetrical configuration in 83%, while 8 received 1 or 2 more injections because of an asymmetrical configuration (75%) and/or low volume. Despite a mean collagen volume of 3.2 cc (range 2 to 4.3) 6 women with persistent stress urinary incontinence underwent a pubovaginal sling procedure. Eight of 25 patients requiring only collagen had stable collagen volume for 2 years without repeat injection.
Collagen injection is a viable option with satisfactory results in this complex population.
The Journal of urology 01/2009; 181(2):701-4. · 4.02 Impact Factor
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ABSTRACT: Interstitial cystitis (IC) is a challenging disease complex. Patients' perception of their outcomes after different treatment modalities may be the best measure of therapeutic efficacy. Our study focused on a large group of women with a diagnosis of IC who reported on perceived outcomes after undergoing invasive and pharmaceutical treatments for their disease.
Seven hundred fifty patients with a diagnosis of IC completed a computerized survey that queried each patient about their demographics, symptoms, concomitant diagnoses, treatments, and their perceived treatment outcomes. The patients were surveyed on therapies used to treat IC and whether they perceived their condition to be improved, not affected or having deteriorated at a mean follow-up of 6 months. Pearson chi-squared tests were used in the statistical analyses.
Invasive and medical therapies were surveyed. The most commonly performed procedures were hydrodistention (61.9%), intravesical therapy (40.1%), and urethral dilatation (26.5%). Of these procedures, 24.4% to 45.3% of patients were improved by these procedures; whereas 27.0% to 49.8% felt no effect and 25.9% to 30.7% worsened. A comparison of the number of patients who improved with those who deteriorated while on medical therapy was found to be significant for all drugs (P <0.001). The majority of patients reported that medications improved their condition, perceptively.
Medical therapy is perceived to be superior to invasive therapy in the treatment of IC. Medication should be considered the first line therapy for IC. Several medications showed a large percentage of patients with improvement in symptoms. These medications were calcium glycerophosphate (Prelief, AkPharma Inc, Pleasantville, NJ), phenazopyridine, and pentosan polysulfate sodium.
Urology 02/2008; 71(1):62-6. · 2.43 Impact Factor
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ABSTRACT: Botulinum toxin A has previously been used for neurogenic and nonneurogenic urgency and urge incontinence. We evaluated the effects of sphincteric botulinum toxin A injection in a series of neurologically normal children with evidence of external sphincter dyssynergia with various voiding problems documented by abnormal voiding electromyography as well as voiding cystourethrography to assess its effectiveness for eliminating post-void residual urine.
We retrospectively reviewed the charts of 16 dysfunctional voiders who underwent botulinum toxin A injection to the external sphincter between 2002 and 2006, including 1 to 3 injections in 14, 1 and 1, respectively. Of 19 injections 17 were performed with 300 U to the sphincter, while 2 of 19 were done with 200 U. Two patients also received 100 U injected into the detrusor. Mean patient age at surgery was 9.0 years (range 6 to 16). Preoperative clinical data were recorded, including medications, electromyography, uroflowmetry with post-void residual urine, ultrasound and voiding cystourethrography. Before botulinum toxin A injection medical therapies had failed in all patients, including alpha-blockers in 100%, biofeedback in 100%, oxybutynin in 33% and tricyclics in 3 (20%). One patient was on intermittent catheterization. All patients were refractory to bowel regimens and timed voiding. Postoperative parameters consisted of medications, symptoms and post-void residual urine. In the 3 males the resolution of epididymitis symptoms and prevention of recurrence were evidence of success.
Before treatment patients experienced symptoms of urge incontinence (14 of 16), recurrent urinary tract infections (66%), voiding postponement (45%) and epididymitis (3 of 16). All patients had external sphincter dyssynergia, as documented by preoperative electromyography or voiding cystourethrography. Average preoperative post-void residual urine was 107 cc (range 49 to 218). Two patients who underwent preoperative voiding cystourethrography had unilateral grade 1 reflux. Of the 16 children 12 (75%) were dry at the first postoperative visit. The remaining 2 patients had decreased enuresis and 13 of 16 were dry at the second postoperative visit. The last patient became dry after treatment for attention deficit disorder was initiated. Average initial postoperative post-void residual urine volume was 43 cc (range 0 to 141) and the average best postoperative visit post-void residual urine was 8 cc (range 0 to 26). Uroflow data revealed no difference in uroflow before or after injections. Neuropsychiatric problems were present in 9 of the 16 patients, including depression in 4, anxiety in 3 and attention deficit disorder in 2.
Before our study in the pediatric literature doses between 50 and 100 U were used. We used a significantly higher dose with increased efficacy and no increased morbidity. Endoscopic botulinum toxin A injection of the external sphincter appears to be a safe and efficacious way to treat refractory nonneurogenic voiding dysfunction in children with external sphincter dyssynergia. Long-term followup is necessary and repeat endoscopic injections may be required in select patients.
The Journal of Urology 11/2007; 178(4 Pt 2):1775-9; discussion 1779-80. · 3.75 Impact Factor
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Expert Review of Medical Devices 10/2007; 4(5):675-9. · 2.63 Impact Factor
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ABSTRACT: Substantial controversy exists in the literature regarding the association between pretreatment testosterone and disease outcome in patients with prostate cancer. We explored the relationship between preoperative total testosterone, and pathological stage and progression in patients with clinically localized prostate cancer treated with radical prostatectomy.
We retrospectively reviewed the records of consecutive patients with clinically localized prostate cancer treated with radical prostatectomy between January 1990 and June 2003. A total of 326 patients with pretreatment testosterone levels available were eligible for this analysis. Biochemical progression (BCR) was defined by postoperative prostate specific antigen (PSA) greater than 0.4 ng/ml with a confirmatory increase and it occurred in 41 men. No men received adjuvant therapy. Univariate and multivariate logistic regression analyses were done to examine whether pretreatment testosterone was associated with pathological stage. Cox regression was used to assess the association of testosterone and BCR.
Median PSA was 6.01 ng/ml (range 0.13 to 86), testosterone was 385 ng/dl (range 133 to 998) and followup was 36 months (range 4 to 136). In 245 patients (75%) disease was organ confined. Lower testosterone correlated with adverse pathological stage on multivariate analysis (p = 0.01), as did clinical stage, biopsy grade and PSA. However, we found no relationship between testosterone and BCR after adjusting for covariates. Furthermore, we found no evidence of an interaction between PSA and testosterone (p = 0.4).
On multivariate analysis low preoperative total testosterone was associated with advanced pathological stage but not with BCR. Future studies are warranted with data on more patients who have progressed.
The Journal of Urology 07/2005; 173(6):1935-7. · 3.75 Impact Factor
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Digestive Diseases and Sciences 09/2003; 48(8):1472-4. · 2.12 Impact Factor
