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ABSTRACT: Primary localized amyloidosis of the urinary bladder generally has a benign course. On the contrary, secondary amyloidosis, a consequence of systemic amyloidosis, may have massive bleeding and produce complications such as bladder rupture or life-threatening hemodynamic problems requiring desperate hemostatic procedures such as hypogastric artery embolization or ligature, or cystectomy. We report one case in which hemostasis was achieved by a Mickulicz transurethral bladder tamponage.
58 year old female with very aggressive rheumatoid arthritis and secondary renal amyloidosis under chronic hemodialysis presenting with severe hematuria after hip replacement. An inflamed bladder was found, the biopsy of which showed edema in all layers with blood vessel walls enlarged by amiloyd deposits. After several unsuccessful transurethral hemostatic procedures, intravesical formalin irrigation was carried out together with a Mikulicz type gauze packaging after urethral dilation. The gauze was withdrawn three days later without bleeding recurrence; however she presented subsequent neurological impairment and finally died 14 days after the last urological procedure.
Transurethral packaging of the urinary bladder in a woman with massive hematuria is a hemostatic option that we recommend to be used before other more dramatic or invasive options are chosen.
Archivos españoles de urología 06/2005; 58(4):347-50.
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ABSTRACT: To evaluate the results of a comprehensive treatment of female stress urinary incontinence combining prolene mesh sling and proper gynaecologic repair depending on the kind of prolapse or pelvic floor dysfunction. To analyse short and long term clinical and urodynamic outcomes, and the effect on quality of life and economics associated with female urinary incontinence.
Prospective study including 102 consecutive patients with urinary incontinence; recruitment started in June 1996, ended in March 2002 for this analysis but it continues open currently. History of neurourologic disorders, radiotherapy, oncological diseases, gynaecological diseases and previous surgeries data were recorded in all subjects. History and physical examination were done evaluating urinary symptoms, duration of urinary incontinence, and urinary symptoms oriented examination (incontinence, urgency and urgency-incontinence), as well as gynaecological examination evaluating and grading cystocele, rectocele, uterine prolapse, enterocele and dome prolapse. Complete urodynamics were performed before and after surgery. Surgery was indicated as a complete pelvic floor dysfunction repair including prolene mesh sling in all cases with urinary stress incontinence, hysterectomy or not depending on the existence of prolapse, and anterior/posterior colpoperineorrhaphy with or without mesh. Results on urinary continence, complications and their treatment were evaluated in the postoperative period, on discharge, at 6 months and yearly thereafter.
Average age was 63.8 years (27-82 years, SD 11.2). 39.3% of the patients were over age 70. Mean follow-up was 4.25 years (12-75 months, SD 11.9). The cost of pads for urinary incontinence was 2741.17 Euros per patient (456,117 pesetas). 32.3% of the patients had risk factors for urinary incontinence surgical treatment failure and 18.8% had a leak point pressure below 30 H20 cm. 22.3% cases presented with detrusor instability before surgery. 102 sling procedures, 20 hysterectomies, 26 anterior plasties, 14 posterior plasties, 10 mesh cystocele repair, 1 posterior mesh, and 2 enterocele sacral promontory fixation were performed, accounting a total of 173 surgical procedures during 102 anaesthesia procedures. 9 additional procedures were necessary for the treatment of complications. Stress continence was achieved in 99.01% cases. In half of the patients with preoperative urgency-incontinence it continued during the first postoperative year. 11 cases have postoperative bladder instability, 7 of which had it preoperatively and 4 were de novo.
5 cases needed sling section/reconfiguration because of excess tension (non effective sling). 3 cases needed sling tight stretching/reconfiguration because of less than adequate tension. 2 cases of accidental bladder performation were treated with primary closure and urinary diversion. One case of infection-abscess in the mesh left anchoring stitch was drained under local anaesthesia. There were 6 cases of suprapubic, inguinal and rectal pain (8.1%), in all of them it disappeared within 9 months. There were 2 cases of wound infection.
The prolene mesh sling can offer long term cure for stress urinary incontinence in almost all cases (99.01%), including the complicated ones. 91.1% of the patients underwent one surgical procedure only, and 8.8% required additional procedures. Results stand the test of time with a clinical-urodynamic follow up of 4.25 years. The voiding urgency referred by 81% of the women with large prolapses is associated with demonstrated bladder instability in 63% of the cases. Voiding urgency as well as bladder instability disappeared in all cases but one, being this fact prolapse-correction dependent, so that pelvic prolapse correction plays a decisive role. De novo bladder instability is uncommon (3.9%) and appears randomly in this series.
Archivos españoles de urología 12/2002; 55(9):1057-74.
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ABSTRACT: To report our experience in the diagnosis and treatment of the lower urinary tract obstruction after urinary incontinence corrective surgery, analysing the different techniques performed, retropubic or vaginal urethrolysis.
We report a series of 14 patients with the diagnosis of obstruction after incontinence corrective surgery. They were classified in 2 groups, those who underwent retropubic procedures (5 cases) and those who underwent prolene mesh sling procedures (9 cases). We detail preoperative clinical-urodynamic parameters, and postoperative bladder outlet obstruction confirmation. Retropubic urethrolysis was performed in all patients after retropubic surgery, with the association of hysterectomy if indicated. The performance of a new sling- urethropexy was individualized. In three cases of retropubic surgery repeated urethropexy was not done. Unilateral section was performed in the sling series for all except one case of double section. A new mesh sling was performed in two cases; two cases did not undergo reoperation. Urethrolysis results were evaluated both subjectively by satisfaction degree scales and objectively by clinical-urodynamic evaluation, comparing clinical data and urodynamic parameters using the proper statistical test.
In the retropubic surgery group all patients are continent. Satisfaction degree is: very satisfied 3 patients and 2 quite satisfied. Two presented with voiding urgency not needing anticholinergic drugs, and their urodynamic data returned to normal values without post void residual. The obstructed patients in the sling group reported minimal urgency after urethrolysis in 2 cases. Two patients have stress urinary incontinence: one of them is better than before and refused to undergo a new operation; the other one, who repeated sling, developed a clinical picture of urgency-incontinence again, underwent second section and continues having stress urinary incontinence. Among 7 patients undergoing sling, 4 are very satisfied, 1 quite satisfied, 1 somewhat satisfied and 1 not at all satisfied. Voiding difficulties have disappeared in all cases; comparisons between pre and postoperative urodynamics maximum flow, detrusor pressure at maximum flow and postvoid residual show statistically significant differences. Post-urethrolysis parameters return to preoperative values.
The immediate development of symptoms after surgical correction of urinary stress incontinence is the best diagnostic criteria for obstruction. Detrusor muscle responds to obstruction, but sometimes its response is so minimal that it is difficult to diagnose urodynamically. The knowledge of preoperative values helps to confirm the diagnosis. In any case, urodynamic parameters did not influence the success of urethrolysis. Urethrolysis is an effective operation to cure symptoms secondary to obstruction after incontinence corrective surgery. When a sling has been the procedure performed, probably it is not worth to perform a standard urethrolysis; a simple section of one of the branches seems to be enough to improve symptoms. Currently, there is not scientific evidence about the convenience or not of bladder neck-urethral re-suspension after urethrolysis. The only case-scenario in which it is clearly indicated is that when there is stress incontinence in addition to obstructive symptoms.
Archivos españoles de urología 12/2002; 55(9):1107-14.
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ABSTRACT: Female urethral divertilum is a rare disease; its diagnosis has increased with the use of new diagnostic technologies. It must be suspected in women consulting for chronic irritative symptoms without response to conventional treatments. Transvaginal surgical excision is the most accepted therapeutic option. We reviewed their clinical presentations, diagnostic findings, and therapeutic options and report our experience.
We retrospectively reviewed our case series, finding 4 patients with the diagnosis of female urethral diverticulum; we performed a bibliographic review.
Urethral diverticulum is a rare clinical entity which has to be included in the differential diagnosis of women with chronic lower urinary tract symptoms. Clinical presentation may vary from asymptomatic to rich voiding symptoms. The most frequently used diagnostic method is voiding cystourethrogram; other techniques such as transvaginal ultrasound or MRI are very useful for complicated cases. Surgical treatment by transvaginal diverticulectomy with closure in several layers is the most frequent approach. Postoperative complications are rare.
Archivos españoles de urología 58(1):4-8.