Faculty Bibliography

PURPOSE: Neurogenic bladder is a major problem for children with spina bifida. Despite rigorous pharmacological and surgical treatment, incontinence, urinary tract infections and upper tract deterioration remain problematic. We have previously demonstrated the ability to establish surgically a skin-central nervous system-bladder reflex pathway in patients with spinal cord injury with restoration of bladder storage and emptying. We report our experience with this procedure in 20 children with spina bifida. MATERIALS AND METHODS: All children with spina bifida and neurogenic bladder underwent limited laminectomy and a lumbar ventral root (VR) to S3 VR microanastomosis. The L5 dorsal root was left intact as the afferent branch of the somatic-autonomic reflex pathway after axonal regeneration. All patients underwent urodynamic evaluation before and after surgery. RESULTS: Preoperative urodynamic studies revealed 2 types of bladder dysfunction- areflexic bladder (14 patients) and hyperreflexic bladder with detrusor external sphincter dyssynergia (6). All children were incontinent. Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR microanastomosis. Of the 14 patients with areflexic bladder 12 (86%) showed improvement. In these cases bladder capacity increased from 117.28 to 208.71 ml, and mean maximum detrusor pressure increased from 18.35 to 32.57 cm H2O. Five of the 6 patients with hyperreflexic bladder demonstrated improvement, with resolution of incontinence. Urodynamic studies in these cases revealed a change from detrusor hyperreflexia with detrusor external sphincter dyssynergia and high detrusor pressure to nearly normal storage and synergic voiding. In these cases mean bladder capacity increased from 94.33 to 177.83 ml, and post-void residual urine decreased from 70.17 to 23.67 ml. Overall, 3 patients failed to exhibit any improvement. CONCLUSIONS: The artificial somatic-autonomic reflex arc procedure is an effective and safe treatment to restore bladder continence and reverse bladder dysfunction for patients with spina bifida

OBJECTIVES: To compare the postoperative and quality-of-life outcomes for men experiencing major bleeding after radical retropubic prostatectomy that was managed with reoperation or observation. METHODS: A total of 916 men underwent radical retropubic prostatectomy by a single surgeon between October 2000 and August 2004. Of the 916 men, 15 (1.6%) experienced major bleeding, defined as the transfusion of 3 U or more of allogeneic blood within the first 36 hours after radical prostatectomy. The outcomes were compared between the 5 men undergoing reoperation (group 1) and the 10 men whose bleeding was managed with observation (group 2). RESULTS: The mean total number of allogeneic blood units transfused was significantly greater in group 1 (7.4 U) than in group 2 (4.1 U; P = 0.002). Group 1 also experienced a significantly longer hospital stay (4.6 versus 2.6 days). Those men undergoing reoperation had a significantly lower probability of moderate to severe extravasation on initial cystogram compared with group 2 (0% versus 70%). In addition, the urinary catheter was indwelling for a shorter interval (9.6 versus 23.5 days). We also found a suggestion of better continence in group 1. CONCLUSIONS: Reoperation for major bleeding after radical retropubic prostatectomy facilitates both healing of the vesicourethral anastomosis and removal of the urinary catheter

Expert laparoscopic surgeons have demonstrated that laparoscopic radical prostatectomy with or without robotic assistance can be performed with excellent results. There is no evidence that laparoscopic radical prostatectomy with or without robotic assistance offers any clinically relevant advantage over open radical prostatectomy. Laparoscopic radical prostatectomy with or without robotic assistance requires a significant learning curve, is a longer surgical procedure, carries greater costs, and requires an expanded operating room team. The literature suggests that laparoscopic radical prostatectomy is associated with more intraoperative complications and higher positive surgical margins. The lesser amount of postoperative bleeding associated with laparoscopic radical prostatectomy is not clinically relevant. Laparoscopic radical prostatectomy is not associated with less pain and does not facilitate earlier urinary catheter removal. The best way to improve overall outcomes after radical prostatectomy is to direct patients to expert open or laparoscopic surgeons

Nearly all men will develop histological benign prostatic hyperplasia by the age of 80, but the degree of prostatic enlargement resulting from the hyperplasia is highly variable. Historically, it has often been assumed that the pathophysiology of lower urinary tract symptoms (LUTS) in men is the result of bladder outlet obstruction associated with prostatic enlargement. The observation that prostatic enlargement, bladder outlet obstruction, and LUTS are all age-dependent has been interpreted to indicate that these phenomena were causally related, but there is insufficient evidence for this. Undoubtedly, some men's prostatic enlargement causes obstruction and symptoms. Based on the available data, however, this subset appears to be extremely small. Because of the many urological and nonurological conditions that cause LUTS and age-dependent changes in bladder and neurological function, it is unlikely that there exists a single dominant etiology for the aging male population. If this is the case, then the optimal management of LUTS will require different and possibly combination therapies

OBJECTIVES: To compare the surgical outcomes after radical prostatectomy between men younger than 50 years and men 50 years old or older. METHODS: Between October 1, 2000 and December 31, 2003, 790 men underwent open radical retropubic prostatectomy by a single surgeon. The intraoperative, perioperative, and postoperative parameters were recorded in real time and entered into a database. The outcomes were compared for 66 men younger than 50 years of age (group 1) versus 724 men who were 50 years old or older (group 2). RESULTS: The pathologic stage, percentage of cancer in the surgical specimen, positive surgical margin rate, and Gleason score were not significantly different among the two age groups. No significant difference was found in the risk factors for prostate cancer between groups 1 and 2 (33.3% versus 28.9%, respectively; P = 0.63). The operative complications were exceedingly low in both groups. Of the men in groups 1 and 2, 93.3% and 97.1% achieved continence, respectively (P = 0.26). Of the potent men at baseline who underwent bilateral nerve-sparing prostatectomy, 100% of men in group 1 versus 81.4% in group 2 (P = 0.02) were having erections adequate for intercourse with or without phosphodiesterase-5 inhibitors or intracavernous injection therapy, as determined by direct patient interview. Of the men who underwent bilateral nerve-sparing radical retropubic prostatectomy, 78.3% of group 1 versus 62.6% of group 2 (P = 0.14) were potent with or without phosphodiesterase-5 inhibitors. CONCLUSIONS: The preoperative and pathologic predictors of organ-confined disease and biochemical recurrence were similar in both age groups. The results of this study have demonstrated that radical retropubic prostatectomy can be performed with good results and low complication rates in men with localized prostate cancer who are younger than 50 years of age

Nearly all men will develop histological benign prostatic hyperplasia by the age of 80, but the degree of prostatic enlargement resulting from the hyperplasia is highly variable. Historically, it has often been assumed that the pathophysiology of lower urinary tract symptoms (LUTS) in men is the result of bladder outlet obstruction associated with prostatic enlargement. The observation that prostatic enlargement, bladder outlet obstruction, and LUTS are all age-dependent has been interpreted to indicate that these phenomena were causally related, but there is insufficient evidence for this. Undoubtedly, some men' prostatic enlargement causes obstruction and symptoms. Based upon the available data, however, this subset appears to be extremely small. Because of the many urological and nonurological conditions that cause LUTS and age-dependent changes in bladder and neurological function, it is unlikely that there exists a single dominant etiology for the aging male population. If this is the case, then the optimal management of LUTS will require different and possibly combination therapies

Gonadotropin-releasing hormone (GnRH) agonists are the agents of choice for achieving androgen suppression in men with advanced prostate cancer. The GnRH agonists that have been developed and marketed for prostate cancer are leuprolide, goserelin, triptorelin, and histrelin. So far, there have been few randomized studies directly comparing these single-agent therapies; however, the literature and the data on file with the Food and Drug Administration suggest that triptorelin may be more reliable than leuprolide in maintaining castration levels of serum testosterone. The clinical significance of this benefit remains to be proven

Acute urinary retention (AUR), an uncomfortable and potentially dangerous condition, often occurs in men who have benign prostatic hyperplasia. Although the reported incidence of AUR varies in the literature, there are a number of events that are known to precipitate episodes of AUR, including ingestion of certain agents, infection, general anesthesia, and performance of various diagnostic genitourinary procedures. Because it is preferable to avoid the need for catheterization (and the associated risks) in men at high risk for AUR, certain measures have been studied as means to prevent AUR episodes. Specifically, alpha-blockers and 5-alpha-reductase inhibitors have been shown to reduce the incidence of initial and subsequent AUR episodes in certain at-risk men

Since the early 20th century, radical prostatectomy has been used in the treatment of prostate cancer. However, before the widespread acceptance of prostate-specific antigen screening, the majority of cancers were clinically advanced and not amenable to cure, so relatively few men were candidates for this procedure. Modern advances have contributed dramatically to the reduction of complications and morbidity associated with radical prostatectomy. As a result, the procedure has become the most common treatment selected by men with localized prostate cancer. This article reviews several issues regarding radical prostatectomy, including surgical techniques, cancer control, intraoperative localization of the cavernous nerves, patient selection, and laparoscopic versus robotic approaches