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ABSTRACT: PURPOSE: The authors of this guideline reviewed the literature regarding use of urodynamic testing in common lower urinary tract symptoms. The findings are intended to assist clinicians in the appropriate selection of urodynamic tests, following an evaluation and symptom characterization. MATERIALS AND METHODS: A systematic review of the literature using the MEDLINE® and EMBASE databases (searched from 1/1/90 to 3/10/11) was conducted to identify peer-reviewed publications relevant to using urodynamic tests for diagnosis, determining prognosis, guiding clinical management decisions and improving patient outcomes in patients with various urologic conditions. The review yielded an evidence base of 393 studies after application of inclusion/exclusion criteria. These publications were used to create the evidence basis for characterizing the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinion. RESULTS: The evidence-based guideline statements are provided for diagnosis and overall management of common LUTS conditions. CONCLUSIONS: The Panel recognizes that each patient presenting with LUTS is unique. This Guideline is intended to serve as a tool facilitating the most effective utilization of urodynamic testing as part of a comprehensive evaluation of patients presenting with LUTS.
The Journal of urology 10/2012; · 4.02 Impact Factor
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Neurourology and Urodynamics 02/2012; 31(2):209. · 2.96 Impact Factor
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ABSTRACT: Persistent or recurrent stress urinary incontinence (SUI) after a midurethral sling (MUS) may result from incorrect location of the sling relative to the midurethra. This study's objective was to evaluate the incidence of bladder neck (BN) or more proximal MUS in women undergoing reoperation for SUI after synthetic MUS.
A retrospective review was performed of patients referred and treated for isolated recurrent SUI after synthetic MUS (transobturator or retropubic approach). Patients undergoing sling excision for other indications (eg, outlet obstruction, urinary tract erosion) were excluded. Preoperative video urodynamic (VUDS) parameters were examined. Operative reports at re-exploration provided the anatomic location of the sling.
Fifteen women with SUI after MUS underwent VUDS and subsequent reoperation. The MUS was found proximal to or at the BN in 8 (53%) women and suburethral in 7 (47%). Women with BN or proximal sling location were equally likely to have an open (4/8 patients) or closed BN (4/8 patients) at rest on filling cystography. VUDS parameters, including the radiographic finding of an open BN preoperatively, were not predictive of BN or more proximal sling location intraoperatively. MUSs found at the BN or proximal were more likely to be retropubic slings (7/8 patients). Rates of concomitant anterior prolapse repair did not differ according to sling location.
Recurrent SUI as a result of proximal MUS location cannot be predicted on preoperative VUDS parameters. Surgical exploration is the primary method for identifying this phenomenon as the etiology of failure in these patients.
Urology 01/2012; 79(1):76-9. · 2.43 Impact Factor
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Eric S Rovner
Urology 07/2011; 78(1):213. · 2.43 Impact Factor
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ABSTRACT: As newer materials and less invasive techniques emerge, treatment of stress urinary incontinence has increased over time. This shift has implications for the types of complications seen in contemporary practice compared to those even a few years ago. This review details prevention, diagnosis, and treatment of complications of sling surgery for stress urinary incontinence.
Proper diagnosis and evaluation of stress urinary incontinence remains paramount in preventing surgical complications. Intraoperative complications, primarily bleeding and urinary tract injury vary depending on surgeon experience, operative technique and approach as well as prompt recognition of the injury. Postoperative complications include but are not limited to voiding dysfunction, urinary retention, vaginal extrusion and urinary tract erosion, thigh pain, and sexual dysfunction. Treatment relies on appropriate identification of the complication and may involve conservative and/or eventual surgical measures.
As surgical treatment of stress incontinence evolves, thorough understanding of sling surgery and its attendant complications remain critical for the practicing physician.
Current opinion in urology 07/2011; 21(4):291-6. · 2.50 Impact Factor
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ABSTRACT: To present a modified transvaginal bladder neck closure (TV BNC) technique using a posterior urethral flap to minimize the potential risk of ureteral injury and fistula formation. Urethral and bladder neck destruction owing to chronic indwelling urethral catheters in female neurogenic patients is a devastating complication.
A retrospective review was performed of all patients undergoing TV BNC at a single institution during a 3-year period. All patients had had a nonfunctional or destroyed urethra because of a long-term indwelling urethral catheter. In brief, the devastated outlet was closed using the dorsally bivalved urethra as a flap that was rotated cephalad onto the incised anterior bladder wall for closure, thereby rotating the suture line high into the retropubic space. A postoperative cystogram was obtained at 2-3 weeks.
A total of 11 consecutive female patients with a devastated outlet underwent TV BNC, as described, with placement of a suprapubic tube. One patient experienced failure at 6 weeks postoperatively. The mean follow-up for the entire cohort was 9.6 months (range 1-36). Serial upper tract imaging at the last follow-up visit revealed no new hydroureteronephrosis.
The results of our study have shown that TV BNC with a posterior urethral flap provides satisfactory early results. This technique creates a suture line far removed from the ureteral orifices, minimizing the risk of upper tract injury during closure. Also, the rotation of the posterior urethra onto the anterior bladder wall secures the suture line high into the retropubic space, minimizing the risk of failure and postoperative fistula formation.
Urology 07/2011; 78(1):208-12. · 2.43 Impact Factor
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ABSTRACT: BACKGROUND: Overactive bladder syndrome (OAB) is associated with various co-morbidities; treatment of these frequently results in multiple medication use (MMU) and the potential for drug-drug interactions, which may lead to adverse events and altered efficacy. With the aging population, the prevalence of MMU is likely to increase in the overall population, an increase due in part to treatment of co-morbidities that are more common in the elderly. OBJECTIVE: To assess safety and efficacy outcomes with once-daily trospium chloride 60 mg extended release (XR) in subjects with OAB who were taking multiple concomitant medications. STUDY DESIGN: Post hoc analysis of pooled data from two 12-week randomized, placebo-controlled studies. Setting: Urology, urogynaecology, and primary care offices/clinics. PATIENTS: Subjects aged ≥18 years with OAB for ≥6 months who had baseline urinary frequency of ≥30 toilet voids/3 days; ≥1 'severe' urgency severity rating/3 days (on the Indevus Urgency Severity Scale); and pure urge urinary incontinence (UUI) or mixed incontinence with predominant UUI, with ≥3 UUI episodes/3 days. This analysis utilized data from subjects taking concomitant medications, focusing on those taking seven or more. INTERVENTION: Once-daily trospium chloride 60 mg XR or placebo. MAIN OUTCOME MEASURE: Predictors of treatment-emergent adverse events (TEAEs) identified by multivariate logistic regression analysis. Results: Concomitant medications were being taken by 1135 subjects (placebo, n = 576; trospium chloride XR, n = 559); 427 were taking seven or more (placebo, n = 199; trospium XR, n = 228). Among subjects taking seven or more concomitant medications, there was no significant difference between trospium chloride XR and placebo in the proportion of subjects experiencing one or more TEAEs (64.5% vs 58.3%). Logistic regression analysis indicated that the odds of experiencing a TEAE were influenced by concomitant medication use, but not by randomization assignment to trospium chloride XR or to placebo, suggesting that concomitant drugs contribute more to TEAEs than trospium chloride XR. Compared with subjects taking one to two concomitant medications, the adjusted odds ratio (OR) for experiencing any TEAE was 3.39 (95% CI 2.39, 4.80; p < 0.0001) for subjects taking seven or more concomitant medications. The adjusted OR for experiencing any TEAE for subjects randomized to active treatment compared with placebo was 1.19 (95% CI 0.85, 1.67; p = 0.31). Efficacy in subjects taking seven or more concomitant medications was similar to that in the overall pooled study population. Conclusions: Trospium chloride XR does not increase the likelihood of a TEAE compared with placebo. The probability of experiencing a TEAE was significantly influenced by use of multiple concomitant medications. Trospium chloride XR was as effective in subjects with OAB taking seven or more concomitant medications as in the overall pooled study population. The data support the conclusion that trospium chloride XR is safe and effective in patients with OAB taking multiple concomitant medications.
Drugs & Aging 02/2011; 28(2):151-60. · 2.67 Impact Factor
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ABSTRACT: • To evaluate the safety and efficacy of once-daily trospium chloride extended release (ER) in overactive bladder syndrome (OAB) in subjects aged ≥ 75 years.
• The analysis included subjects ≥ 75 years of age with OAB. • A subgroup analysis of pooled data was performed for subjects aged ≥ 75 years from two randomized, double-blind, multicenter studies of subjects with OAB receiving once-daily trospium 60 mg extended release (ER) or placebo for 12 weeks, followed by 9-month open-label extension periods during which all subjects received trospium ER. A total of 143 of the 1165 subjects from two phase III registration trials who were aged ≥ 75 years (85 trospium ER, 58 placebo; mean age 79 years and ranging up to 90 years; 73% female) were evaluated. • Dual primary efficacy variables were the changes from baseline in the average number of toilet voids per day and urge urinary incontinence episodes per day.
• At week 12 of the double-blind period, trospium ER produced greater improvements from baseline than placebo in voiding diary parameters, OAB Patient Global Assessment, and quality of life. • Efficacy and tolerability persisted among subjects receiving open-label trospium ER for up to 1 year.
• Once-daily trospium chloride 60 mg ER demonstrated efficacy vs placebo and was tolerated in subjects aged ≥ 75 years with OAB. • For subjects who continued into the open-label treatment period, efficacy and tolerability were observed for up to 1 year.
BJU International 02/2011; 107(4):612-20. · 2.84 Impact Factor
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ABSTRACT: To assess the quantitative effect of the 7-F catheter on resultant abdominal leak point pressure (ALPP). The numerical value of ALPP in men with post-prostatectomy incontinence (PPI) may have some utility in directing therapy for this condition. Yet, no standardized method of calculating this value has been agreed upon. It has been suggested that the presence and size of the transurethral urodynamic catheter may affect ALPP.
A retrospective chart review of 20 consecutive men with symptomatic PPI was conducted. Multichannel video-urodynamics were performed using a 7-F transurethral catheter and a rectal catheter. The presence of sphincteric incontinence was elicited using the Valsalva maneuver and ALPP recorded from both vesical and rectal transducers. The transurethral catheter was then removed and ALPP repeated in the absence of a vesical transducer, permitting rectal transducer measurements only. Statistical analysis was performed using Wilcoxon signed-rank test.
The mean age of this cohort was 66.4 years (range 54-78). All men showed a decrease in ALPP when performed without the urethral catheter. Mean ALPP with and without the transurethral catheter was 66.1 cm H(2)O (95% CI, 50.4-81.8 cm H(2)O) and 35.7 cm H(2)O (95% CI, 20.0-51.4 cm H(2)O), respectively (P <.01). A strong correlation between mean ALPP with and without the transurethral catheter was noted (r = .83).
A 7-F transurethral catheter can affect absolute ALPP measurements in men with PPI. In this study, removal of the transurethral catheter resulted in a significant linear decline in ALPP. This finding may have clinical importance in centers where ALPP is used as a factor in determining therapy for PPI. ALPP standardization is needed.
Urology 01/2011; 77(5):1188-93. · 2.43 Impact Factor
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ABSTRACT: The surgical management of pelvic organ prolapse continues to evolve. Recent advancements in techniques and materials have increased the available treatments for pelvic organ prolapse. A current understanding of the benefits and limitations offered by recently introduced materials and techniques is essential to their proper application.
Current surgical therapies for prolapse now include augmentation with synthetic mesh, which may also be utilized as part of a 'kit'. In addition, both laparoscopic and robot-assisted techniques have been developed to address apical vaginal prolapse. Both the use of synthetic mesh and laparoscopic and robotic techniques should continue to be subjected to appropriate scrutiny to assess their long-term success and complications.
While the introduction of novel approaches to pelvic organ prolapse provide further options when considering appropriate therapy, the application of these materials and techniques should be examined with scientific rigor and should demonstrate both a significant benefit and low morbidity prior to widespread adoption. With continued research, we hopefully will be able to identify the ideal approaches and repairs to achieve optimal patient outcomes.
Current opinion in urology 11/2010; 20(6):490-4. · 2.50 Impact Factor
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ABSTRACT: Overactive bladder (OAB) is a clinical syndrome characterized by urinary urgency, frequency, and nocturia with or without accompanying urinary incontinence. Thus, using this operational definition based on symptoms at presentation, urodynamic testing is not required for an initial diagnosis of OAB. An increasing body of evidence suggests that, although there is a relationship between the urodynamic finding of detrusor overactivity and OAB, these are quite separate findings, and successful response to nonsurgical and surgical interventions for OAB does not depend on finding detrusor overactivity on urodynamic testing. The role of urodynamics in the setting of OAB is not well defined at present, but there are several clinical scenarios where such testing may be useful. However, at this time, the evidence to support their routine use in patients with OAB is limited.
Current Urology Reports 09/2010; 11(5):343-7.
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ABSTRACT: Injectable agents are frequently used in the treatment of stress urinary incontinence in a variety of patients. Materials and techniques used in this therapy have evolved over time, with the relatively recent introduction of several novel therapies. The publication of recent evidence regarding these newer agents as well as older materials has provided fuel for the debate over which therapy is best.
Each of the agents discussed in this paper has variable biophysical properties that affect its efficacy and safety. Despite increasing evidence evaluating the various injectable materials for the treatment of stress incontinence, there is no clear data to establish any agent as superior or inferior in the various subgroups in which they are used.
The ideal periurethral injectable agent has not yet been identified though many of the currently used agents have acceptable efficacy in selected populations. There is active research into novel therapies that may prove effective.
Current opinion in urology 07/2010; 20(4):296-301. · 2.50 Impact Factor
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Roger R Dmochowski,
Jerry M Blaivas,
E Ann Gormley,
Saad Juma,
Mickey M Karram,
Deborah J Lightner,
Karl M Luber, Eric S Rovner,
David R Staskin,
J Christian Winters,
Rodney A Appell,
Linda E Whetter
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ABSTRACT: We updated the 1997 American Urological Association guideline on female stress incontinence.
MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions.
A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category.
The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.
The Journal of urology 03/2010; 183(5):1906-14. · 4.02 Impact Factor
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ABSTRACT: To determine whether the presence of detrusor overactivity (DO) in patients with overactive bladder (OAB) and urgency urinary incontinence (UUI) is a predictor of the response to treatment with fesoterodine.
This phase 2 randomized, multicentre, placebo-controlled trial consisted of a 1-week placebo run-in phase followed by an 8-week double-blind period. Eligible for the study were men and women aged 18-78 years with symptoms or signs of OAB with UUI; they were stratified into two balanced strata depending on the outcome of a baseline urodynamic assessment. By using this particular study design it was possible to investigate whether there were differences between the strata. The primary endpoint was the change from baseline to week 8 in mean voids/24 h. Secondary endpoints were the changes in UUI episodes/week, and for those patients with DO at baseline, the mean changes in volume at first involuntary contraction associated with a feeling of urgency, first desire to void, and strong desire to void, and change in maximum cystometric capacity. Because there were few patients the secondary analyses were considered exploratory.
Overall, there were linear dose-response relationships for placebo and the fesoterodine groups for the reduction in the number of voids/24 h and UUI episodes/week. Compared with the placebo group, the least squares mean changes from baseline to week 8 in both variables were significantly improved in patients receiving fesoterodine 4 mg (P = 0.045 and 0.040, respectively), 8 mg (P < 0.001 for both), and 12 mg (P < 0.001 for both). There were no significant differences in treatment responses, as measured by both variables between patients with and without DO. For patients with DO, the mean volume at the first desire to void improved in all fesoterodine treatment groups and worsened in the placebo group.
Regardless of the presence of DO, the response to fesoterodine treatment was dose-proportional and associated with significant improvements in OAB symptoms, indicating that the response to OAB pharmacotherapy in patients with UUI was independent of the urodynamic diagnosis of DO.
BJU International 11/2009; 105(9):1268-75. · 2.84 Impact Factor
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ABSTRACT: To evaluate patient-reported reasons for discontinuing antimuscarinic prescription medications for overactive bladder (OAB).
A phase 1 screening survey was sent to a representative sample of 260 000 households in the USA to identify patients using antimuscarinic agents for OAB. A detailed phase-2 follow-up survey was sent to 6577 respondents with one or more antimuscarinic prescriptions for OAB in the 12 months before the phase 1 survey. The follow-up survey included questions about demographics, clinical characteristics, antimuscarinic use, beliefs about OAB, treatment expectations, OAB symptom bother, and pre-coded reasons for discontinuation. Patients who reported discontinuing one or more OAB medication during the 12 months before phase 2 were grouped by reason, using latent class analysis (LCA); the Lo-Mendell-Rubin likelihood statistical test was used to determine the number of classes. Conditional probabilities of reasons for discontinuation were calculated for each class. Multivariable logistic regression was used to assess the influence of demographic and clinical characteristics on class assignment.
In all, 162 906 (63%) and 5392 (82%) useable responses were returned in phases 1 and 2, respectively; the demographics were similar in respondents and nonrespondents in both phases. In all, 1322 phase 2 respondents (24.5%) reported discontinuing one or more antimuscarinic drugs during the 12 months before phase 2. LCA identified two classes (Lo-Mendell-Rubin statistic, P = 0.01) based on reasons for discontinuation. Most respondents (89%) reported discontinuing OAB medication primarily due to unmet treatment expectations and/or tolerability; many respondents in this class switched to a new antimuscarinic agent. A smaller group (11%) indicated a general aversion to taking medication. Age, sex, race, income, and history of incontinence were not predictive of class assignment.
Expectations about treatment efficacy and side-effects are the most important considerations in discontinuing OAB medications for most patients. Interventions to promote realistic expectations about treatment efficacy and side-effects might enhance adherence.
BJU International 11/2009; 105(9):1276-82. · 2.84 Impact Factor
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ABSTRACT: The Overactive Bladder Innovative Therapy Trial during phase 1 was a randomized trial demonstrating comparable effectiveness of percutaneous tibial nerve stimulation and extended-release tolterodine during 12 weeks of therapy for frequency, nocturia, urgency, voided volume and urge incontinence episodes. In this second phase of the Overactive Bladder Innovative Therapy Trial we assessed the sustained therapeutic efficacy of percutaneous tibial nerve stimulation in subjects with overactive bladder during 1 year.
After 12 weeks subjects randomized to weekly percutaneous tibial nerve stimulation with Urgent((R)) PC were offered an additional 9 months of treatment with assessments at 6 and 12 months from baseline. Outcome measures included voiding diary data, overactive bladder questionnaires, global response assessments and safety assessments.
A total of 33 percutaneous tibial nerve stimulation responders continued therapy with 32 and 25 subjects completing 6 and 12 months of therapy, respectively. Subjects received a mean of 12.1 treatments during an average of 263 days, with a mean of 21 days (median 17) between treatments. Subject global response assessments showed sustained improvement from 12 weeks at 6 and 12 months, with 94% and 96% of responders, respectively. At 12 months mean improvements from baseline included a frequency of 2.8 voids daily (p <0.001), urge incontinence of 1.6 episodes daily (p <0.001), nocturia with 0.8 voids (p <0.05) and a voided volume of 39 cc (p <0.05). Overactive bladder questionnaire symptom severity was significantly improved from 12 weeks to 12 months (p <0.01) as well as from 6 to 12 months (p <0.01). No serious adverse events occurred.
Statistically significant overactive bladder symptom improvement achieved with 12 weekly percutaneous tibial nerve stimulation treatments demonstrates excellent durability through 12 months. The durability of response demonstrates the effectiveness of percutaneous tibial nerve stimulation as a viable, long-term therapy for overactive bladder.
The Journal of urology 11/2009; 183(1):234-40. · 4.02 Impact Factor
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The Journal of family practice 10/2009; 58(10 Suppl):S1-11; quiz S12. · 0.61 Impact Factor
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Kenneth M Peters,
Scott A Macdiarmid,
Leslie S Wooldridge,
Fah Che Leong,
S Abbas Shobeiri, Eric S Rovner,
Steven W Siegel,
Susan B Tate,
Barry K Jarnagin,
Peter L Rosenblatt,
Brian A Feagins
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ABSTRACT: The Overactive Bladder Innovative Therapy trial was a randomized, multicenter, controlled study that compared the effectiveness of percutaneous tibial nerve stimulation to extended-release tolterodine. The reduction in overactive bladder symptoms along with global response assessments was evaluated.
A total of 100 adults with urinary frequency were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or to 4 mg daily extended-release tolterodine. Voiding diaries and an overactive bladder questionnaire were completed at baseline and at the end of therapy to compare 24-hour voiding frequency, urinary urge incontinence episodes, voids causing waking, volume voided, urgency episodes and quality of life indices. Global response assessments were completed by subjects and investigators after 12 weeks of therapy.
The global response assessment demonstrated that subject assessment of overactive bladder symptoms compared to baseline was statistically significant in the percutaneous tibial nerve stimulation arm with 79.5% reporting cure or improvement compared to 54.8% of subjects on tolterodine (p = 0.01). Assessments by investigators were similar but did not reach statistical significance (p = 0.05). After 12 weeks of therapy objective measures improved similarly in both groups for reductions in urinary frequency, urge urinary incontinence episodes, urge severity and nighttime voids, as well as for improvement in voided volume. There were no serious adverse events or device malfunctions.
This multicenter, randomized trial demonstrates that percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient assessment of overactive bladder symptoms, and with objective effectiveness comparable to that of pharmacotherapy. Percutaneous tibial nerve stimulation may be considered a clinically significant alternative therapy for overactive bladder.
The Journal of urology 08/2009; 182(3):1055-61. · 4.02 Impact Factor
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Eric S Rovner
Urology 12/2008; 72(5):1049. · 2.43 Impact Factor
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ABSTRACT: With a history spanning more than 3 centuries, Charleston, South Carolina was one of the initial locations of urological teaching in the southern United States. The Medical University of South Carolina was chartered in 1823 and is the oldest medical school in the South. We reviewed the historical archives of the Waring Library of the Medical University of South Carolina, specifically the history of urological practice in the city, including doctoral dissertations from medical school students regarding the teaching and practice of urology in pre-Civil War Charleston, to better understand the early development of the specialty.
We reviewed graduate medical student dissertations from the historical archives of the Medical University of South Carolina from 1824 to 1860. In addition, we accessed and reviewed the records of the Medical Society of South Carolina, The Charleston Medical Journal and Review, and The American Urological Association Centennial History 1902 to 2002 volumes 1 and 2.
These historical documents and dissertations review in depth various medical conditions, diagnoses and treatments in pre-Civil War Charleston. Topics such as urolithiasis, urethral stricture, stone composition and hydrocele are a few of the areas considered. Review of these documents fosters insight into the evolving diagnosis and treatment of several urological conditions. Some treatments such as the use of tobacco for urinary retention have fallen out of favor, while others such as the surgical repair of vesicovaginal fistula are still practiced.
The history of urology in pre-Civil War Charleston and at the Medical University of South Carolina demonstrates an advanced understanding of urological diseases and the technology designed to treat them with a distinctly European influence.
The Journal of urology 09/2008; 180(2):477-80. · 4.02 Impact Factor
