Faculty Bibliography

Reconstruction of the female urethra is accomplished by adherence to several basic principles: anatomic considerations with special attention to concomitant incontinence; reconstruction in a multilayered fashion with healthy, well-vascularized tissues; use of local tissue flaps as an additional layer of tissue; and avoidance of the use of synthetic materials in the setting of complex urethral reconstruction. In cases in which reconstruction can be accomplished by primary closure, the mucosa and periurethral fascia should be maintained as individual layers. Vaginal epithelium or labial tissue can be harvested and rotated into place for additional coverage or urethral replacement in cases of stricture. Simultaneous pubovaginal sling placement is advocated in cases of intrinsic sphincter deficiency and incontinence to improve postoperative outcomes after flap urethroplasty for treatment of stricture disease. When distal urethral obstruction is found, the most definitive method of repair is distal urethrectomy and advancement meatoplasty

PURPOSE: The success rate of vesicovaginal fistula repair is improved by tissue interposition. The Martius flap produces reliable results but it has increased morbidity. A peritoneal flap is easily created with minimal morbidity and it can be used for proximal fistulas. We describe our 10-year experience with tissue interposition for transvaginal repair of vesicovaginal fistulas. MATERIALS AND METHODS: From January 1991 to July 2001, 207 cases of vesicovaginal fistulas were repaired transvaginally. Tissue interposition was used for complex (greater than 2 cm. and/or radiation induced) fistulas and/or failed previous repairs. A peritoneal flap was used for proximal fistulas and a Martius flap was used for distal fistulas. A full-thickness labial flap was reserved for cases of insufficient vaginal epithelium. RESULTS: A total of 207 patients underwent transvaginal repair of a vesicovaginal fistula. Etiology of the fistula was hysterectomy in 91% of cases (abdominal in 83% and vaginal in 8%), radiation in 4% and 5% other (obstetric trauma, anterior colporrhaphy or an indwelling catheter) in 5%. In 159 patients (77%) at least 1 previous repair had failed. Repair in 120 patients (58%) was done with tissue interposition, including a peritoneal, Martius and full-thickness labial flap in 83, 34 and 3, respectively. The cure rate after initial repair with a peritoneal, Martius and labial flap was 96%, 97% and 33%, respectively. There were no intraoperative complications. CONCLUSIONS: A peritoneal flap for transvaginal repair of vesicovaginal fistulas has minimal morbidity, results in a success rate comparable to that of the Martius flap and is especially useful for proximal fistulas when previous repair has failed

The morbidity of radical prostatectomy is minimized by identifying men who are at significant cardiovascular risk and excluding them from the procedure. Preoperative management designed to minimize surgical and medical complications and exposure to allogenic blood products increases the benefit-to-risk ratio of radical prostatectomy over other treatment options for localized prostate cancer

Urethral obstruction is a consequence of surgery to treat stress incontinence in women. Although its incidence is relatively low, it still presents a challenging problem for the urologist. Recent work has focused on clarifying the etiology and incidence of this condition, as well as providing new definitions on bladder-outlet obstruction in women. In addition, effective, less invasive ways of treating this condition have been described

OBJECTIVES: To determine whether the response to recombinant erythropoietin is dose dependent in men undergoing radical prostatectomy and to elucidate the relative cost-effectiveness of two dosing regimens. METHODS: A prospective, open-label study comparing the effectiveness, cost, and safety of two different doses of recombinant erythropoietin was performed in men undergoing radical retropubic prostatectomy. The first 100 men received 600 IU/kg (high dose) of epoetin alfa. A second group of 100 men received 300 IU/kg (low dose). All men received two doses of erythropoietin on preoperative days 14 and 7, provided their baseline hematocrit levels were less than 48%. Hematocrit levels were measured at baseline (more than 14 days before surgery), at the time of anesthesia induction, in the recovery room postoperatively, on the first postoperative day, and on the morning of discharge. RESULTS: The mean increase in hematocrit from baseline to induction for the high and low-dose groups was 4.50 and 4.69, respectively (P = 0.7225). Six men (6%) in the high-dose group and seven (7%) in the low-dose group required allogenic blood transfusions. The mean cost of high and low-dose epoetin alfa was $1218 and $656, respectively. The cost per percentage point increase in hematocrit in the low-dose group was significantly less than in the high-dose group. No thromboembolic events occurred in the high or low-dose group. CONCLUSIONS: In men undergoing radical retropubic prostatectomy, the administration of epoetin alfa on preoperative days 14 and 7 was a safe and effective treatment strategy for reducing the risk of allogenic blood transfusions. The 300 IU/kg dosing regimen was significantly more cost effective than the 600 IU/kg dosing regimen

PURPOSE: The safety and effects on hematocrit of recombinant human erythropoietin (epoetin alfa) were evaluated in men undergoing radical retropubic prostatectomy. MATERIALS AND METHODS: Between February 1, 1997 and November 2, 1998, 305 men with clinically localized adenocarcinoma of the prostate underwent radical retropubic prostatectomy performed by a single surgeon (H. L.). Of these men 283 with a baseline hematocrit of less than 48% received 600 IU/kg. epoetin alfa 14 days (-14) and 7 days (-7) before radical retropubic prostatectomy. Hematocrit was measured at baseline on day -14, on day -7, just before anesthesia induction on day 0, immediately postoperatively and on the day of discharge home. The number of allogeneic units transfused, and all intraoperative and postoperative complications were recorded. RESULTS: Mean hematocrit at baseline on day -14 and at induction on day 0 was 42.9% and 45.8%, respectively (p = 0.0001). The frequency of hematocrit decreasing, showing no change or increasing 0.1 to 1.9, 2.0 to 3.9 or greater than 4.0 hematocrit points was 16.5%, 0.5%, 23%, 22% and 38%, respectively. Of the men 17% had no increase in hematocrit. A weak correlation existed between baseline hematocrit and the erythropoietic response to epoetin alfa (r2 = 0.06). Mean change in hematocrit after treatment with epoetin alfa in the quartile baseline hematocrit groups 34.2 to 41.4, 41.5 to 43.2, 43.3 to 44.9 and 45.0 to 48.0 hematocrit points was 3.71, 2.45, 3.86 and 1.02 hematocrit points, respectively. Of the surgical candidates 22 (9.1%) achieved an induction hematocrit of greater than 51%. Of the 283 men receiving epoetin alfa 21 (7.4%) also received an allogeneic transfusion. The transfusion rate did not correlate with induction hematocrit. The only adverse cardiovascular event was an uncomplicated postoperative pulmonary embolus. CONCLUSIONS: Our prospective study demonstrates that epoetin alfa given preoperatively in 2 doses of 600 IU/kg. is safe for significantly increasing hematocrit in men before radical retropubic prostatectomy. It is intuitive that the significant increase in hematocrit decreases the requirement for allogeneic blood transfusion

Expression of a sarcoma proto-oncogene, c-lyn, was mapped in the adult rat brain using immunohistochemistry. Lyn protein was prevalent in restricted cell populations of the olfactory bulb and the basal forebrain which included nuclei of accumbens, fundal striatum, bed stria, ventral pallidum and central amygdala as well as deep entorhinal and pyriform cortices. Tightly packed Lyn-positive cells formed discrete multiple stripes crossing perpendicular to the rostral limb of the anterior commissure, and intense masses surrounding the caudal limb. In the thalamus, the habenula, anterodorsal nucleus and medial geniculate body, together with the paraventricular hypothalamic nuclei, had prominent reactive neuronal somata and dendrites in the neuropil. The lateral septal nucleus also had intense Lyn-positive neurons with overlapping dendritic fields. In addition, scattered neurons were evenly distributed throughout the striatum. The red, interpeduncular, auditory and trigeminal tract nuclei were intensely reactive. The cerebellar molecular layer was uniformly labeled except for a few isolated fiber bundles in the lowest part of this layer. The granule cells adjacent to the Purkinje cell layer appeared in reactive patches. In the spinal cord, the posteromarginal nucleus had intense labeling. The significance of this highly localized distribution pattern of Lyn protein may be related to connections forming functional compartments serving signal transduction within specific central nervous system circuitry