[Acute urinary obstruction]

Acute urinary obstruction is a painful occurrence well known to every physician. It is a matter of a reflexogenic closure of the bladder neck. As the nerves, regulating the neck as well as the motoricity of the bladder, extend directly over the capsule of the prostate, functional disorders during growth of the prostate are possible at any time, independent of the prostatic volume. Since in case of prostatic hyperplasia the smooth muscles of the bladder neck are partly transformed into fibrous tissue, drug treatment in case of acute urinary obstruction is impossible. Therefore catheterisation is applied now as before.

Reversibility of long-standing urinary tract obstruction requiring long-term dialysis

Urinary tract obstruction of longer than 4 to 6 weeks' duration is usually said to be irreversible. Older reports of unilateral obstruction have documented return of kidney function after longer periods of obstruction. The duration of bilateral obstruction compatible with return of life-sustaining renal function is poorly defined. We report herein three cases of long-standing urinary tract obstruction leading to apparent dialysis-dependent end-stage renal disease, where relief of obstruction eventually led to discontinuation of dialysis.

Experience with the intraprostatic spiral

Thirty-six patients have been followed up after insertion of an indwelling intraurethral device for prostatic obstruction. Follow-up exceeded 1 year in some cases. The main problem was dislocation of the spiral not only in the early stages but also after several months. Endoscopic assessment of the obstruction seems important during the pre-operative investigations. The ideal indication is prostatic obstruction in patients who are unsuitable for surgery and who need relief of acute retention for a limited time only. In selected patients the prostatic spiral has a place in the treatment of obstructive prostatism.

[Hydroelectric shock wave in the treatment of complex urethra obstruction]

Twenty-one patients with traumatic complex urethral obstruction were treated by hydroelectric shock wave (HSW). In the 21 patients, anterior urethral stricture was noted in 3 and posterior urethral obstruction in 18. The length of obstruction was 0.5-6cm. 15 patients were cured by single hydroelectric shock wave, 3 by HSW and electric resection, 2 by HSW with open operation, and 1 failed. The follow-up of 19 patients for 3 to 43 months showed no recurrence of urethral obstruction. The classification of traumatic complex urethral obstruction and the points for attention during treatment of hydroelectric shock wave are discussed.

[Intraprostatic prostheses]

We evaluated the usefulness of the intraprostatic spiral prosthesis as an alternative to surgical treatment of benign prostatic hyperplasia (BPH) (40 cases), cancer of the prostate (7 cases), and cervico-prostatic sclerosis (2 cases). These 49 prostheses were placed in elderly patients (mean age 79 years) who had a long indwelling urethral catheter (mean 6.2 months) and were at high risk for surgery (ASA IV 83.6%). In 17% of the cases, placement of the prosthesis permitted performing curative surgery subsequently, once patient general condition had improved. Overall, good results were achieved in 63% (53 patients with BPH) of the cases who tolerated the long indwelling prosthesis well (mean 22 months). The results were assessed according to the quality of micturition (normal in 74.3%), correct placement of the stent (80%), no post-micturition residual volume (88.5%), and a flow rate of 6-12 ml/sec. (60%). Poor results (9 cases) owing to migration of the stent (7 cases) and/or complications: perforation of urethra (1 case), secondary stricture (1 case) and partial calcification of the prosthesis (1 case). The advantages and disadvantages of other currently utilized stents (Prostakath, Variospire, Wall-Stent, and Double Pezzer) are discussed.

Prostatic urethroplasty with balloon catheter as a nonsurgical alternative for benign prostatic hyperplasia

Prostatic urethroplasty with a balloon catheter is an easy procedure to perform, but certain guidelines must be followed to avoid complications. This procedure will reduce the overall treatment cost of benign prostatic hyperplasia significantly. Preliminary results range from 70% to 85% symptomatic improvement or resolution of the prostatism symptoms. Its recurrence rate is still not known, but a small one is expected. Nevertheless, because of the noninvasiveness, low cost, and simplicity of the procedure, it potentially could be repeated, if necessary. This procedure is one that when it is done in combination with another specialist, in this case a urologist, the patient will benefit by the use of the expertise of both the urologist's knowledge of the disease of the urinary system and the interventional radiologist's skills with catheters and guide wires.

Prostatic urethra dilatation with the Gianturco self-expanding metallic stent: a feasibility study in cadaver specimens and dogs

In an effort to develop a transcatheter technique for dilatation of the prostatic urethra without the use of balloons, the feasibility of using Gianturco self-expanding stents was evaluated. Initially, eight human cadaveric prostatic urethras were stented to evaluate the ability of the stent to dilate the lumen. In all cases, the device attained its unconstrained diameter immediately on placement. Subsequently, stents were placed in the prostatic urethra of 12 dogs and followed up for 1 month (four dogs), 3 months (one dog), and 6 months (seven dogs). Five bare straight-end prostheses, one nylon-covered straight-end device, and six flared-end stents were used. Three of the bare straight-end stents migrated during the follow-up, whereas the nylon-covered and flared-end stents did not. Stent diameters greater than 1.3 times the urethral diameter caused moderate to marked edema and inflammation. After 6 months, white deposits were found on the solder points, presumably from electrolysis. Our experience suggests that placement of Gianturco self-expanding stents may be a useful method of dilating and maintaining the luminal diameter of the prostatic urethra, although care must be taken to select the proper stent size.

[The urological spiral. A real alternative to the indwelling catheter? Experience in 23 patients]

Our experiences are reported with the "intraprostatic spiral" in 23 high-risk patients with prostatic adenoma. The intraprostatic spiral was used only in selected patients for medical indications. Patients confined to bed as well as those with detrusor instability or secondary dilatation of the upper urinary tract were excluded. 14 of our patients (60.8%) showed excellent voiding ability, without residual urine and all of them were fully satisfied with the functioning of the prostatic spiral. The longest indwelling time in this group is now about 36 months. 9 of 23 patients (39.2%) were not satisfied with their prostatic spiral. In all of them, the spiral had to be removed later on. Urinary stress incontinence was the main reason for removal. Two thirds of the patients who were not satisfied with the functioning of the prostatic spiral, had a marked decrease in detrusor function. This is a major reason for unsatisfying prostatic spiral function. On average, the prostatic spirals had to be exchanged after 15-18 months because of incrustation. Nearly all patients (21 of 23) showed asymptomatic bacteriuria.

Fetal posterior urethral valve syndrome: a prospective application of antenatal prognostic criteria

A case of posterior urethral valve syndrome is presented. Four weeks after a normal 24-week ultrasound examination, diminished amniotic fluid, megacystis, and renal hyperechogenicity were observed. A repeat ultrasound examination at 30 weeks' gestation identified oligohydramnios and increased renal echogenicity. These findings prompted the performance of a percutaneous cystocentesis to assess fetal renal function indirectly. The specimen was evaluated for osmolality and sodium and chloride concentrations. The urine electrolyte concentrations (sodium 115 mEq/L; chloride 93 mEq/L) and the osmolality (230 mOsm/L) were elevated, suggesting impaired renal function and a poor prognosis. Despite these findings, aggressive management was used, including administration of antenatal corticosteroids and elective preterm delivery. A percutaneous cystocentesis was required during the infant's initial resuscitation, followed by a difficult urethral catheterization. Ultimately, a vesicostomy performed on day 4 of life was associated with prompt return of renal function (serum creatinine 0.7 mg/dL at the time of discharge). At 6 months of age, normal renal function has been documented and the vesicostomy has been closed. This case demonstrates the potential limitations of available prognostic criteria in evaluating fetal urinary obstruction and residual renal function. In selected cases (when the onset of obstruction is documented in the third trimester), refinement of these prognostic criteria may be indicated. Similar cases may be best managed by preterm delivery and prompt postnatal decompression.

[The Fabian prosthesis: our experience in 13 cases]

The spiral intraurethral prosthesis is a device that maintains the urinary tract expedite and overcomes the prostatic obstacle. It is used as an alternative in patients requiring permanent bladder catheters due to prostatic obstruction syndrome that are at high risk for surgery and in those patients that are on the waiting list for surgery. We report the results of a one-year follow-up of 13 patients in whom a prosthesis had been implanted. The spiral prosthesis had to be removed in 6 cases (one due to calcification two months after placement); the remaining 7 patients are still being followed. We briefly analyze the micturition hydrodynamics and the changes of the continence mechanisms and attempt to explain the poor flowmetry results and incontinence observed in these patients with the urological spiral prosthesis. We have recently abandoned the metal prosthesis and now use the so-called "intraureteral catheter" which has become available. However, further experience is warranted in order to determine its results.

Wallstent endoprostheses for the relief of prostatic urethral obstruction in high risk patients

Twenty-one patients with prostatic urethral obstruction who were unfit for surgery were treated with self-expandable stainless steel endoprostheses inserted under fluoroscopic guidance. The procedure was technically successful in all patients, although in one case a second stent was required 2 months later. One patient developed a urethral stricture in the 12-16 month follow up period. One case of epididymoorchitis and one case of septicaemia after stenting were treated successfully with antibiotics. Endoprostheses represent a satisfactory alternative to prostatectomy in high-risk patients.

Balloon dilation of prostatic urethra

Retrograde balloon catheter dilation of the prostatic urethra was performed for the management of bladder outlet obstruction secondary to prostatic hyperplasia. Of the 55 patients in our series, 43 were treated entirely as outpatients and 12 were inpatients for unrelated conditions. The patient selection was limited to older, high-risk patients who were poor surgical candidates for transurethral resection of the prostate or suprapubic prostatectomy because of underlying medical problems. Twenty-two of these patients had Foley catheters for relief of their outflow obstructions. The procedures were performed under local anesthesia or intravenous sedation. Successful results were noted in 46 of 55 patients with relief of symptoms for up to twenty-six months. In 9 cases the procedures were unsuccessful and transurethral resection of the prostate was required.

Permanently implanted urethral stent for prostatic obstruction in the unfit patient. Preliminary report

We describe the use of a new urethral stent implanted into 12 patients with prostatic outflow obstruction. All were in a high risk group for surgery and 11 were treated successfully, with a follow-up of 1 to 11 months (median 9). The majority of patients were satisfied with the procedure, which provided a quick, safe and effective alternative to conventional surgical treatment. The stent, woven from fine stainless steel in the form of a tubular mesh, was inserted via a delivery device using combined ultrasound and endoscopic control under local anaesthesia. The procedure was well tolerated, the stent becoming covered with epithelium by 6 to 8 months following insertion, yet allowing easy removal within the first 4 to 6 weeks should the need arise. This technique provides a useful alternative to conventional surgical treatment in the high risk patient.

Prostatic stents and balloon dilatation

Prostatic obstruction of urinary flow is a common age-related event resulting in both troublesome symptoms and retention of urine. There have been recent developments in the management of such patients by inserting metallic stents or by balloon dilatation of the prostatic urethra. The role of these treatments as alternatives to surgery is evaluated and some of the difficulties encountered in their usage are described in this article.

[Valves of the posterior urethra in the small infant. The surgeon's role and point of view]

The treatment of urinary obstruction by urethral valves is now performed in the newborn since the anomaly is recognized early on by ultrasonography. Its seems that the final result concerning recovery of renal function and urodynamic condition can be obtained by the primary destruction of valves better than by multiple operations following high urinary diversion. An unresolved problem is the persistence of urinary leakage following the treatment of such severe urinary obstructions.

Balloon dilatation of the prostate: technique and early results

Fourteen men with outflow obstruction were treated by balloon dilatation of the prostatic urethra using 25 and 30 mm balloon catheters. Significant improvement in objective measurement of outflow obstruction was noted in only 2 patients.

[Local prostatic hyperthermia in the therapy of urinary obstruction caused by prostatic adenoma. Experimental, clinico histologic and structural findings]

A specifically designed system of selective prostate heating was used to treat 197 patients with prostatic diseases: 164 benign prostatic hypertrophy cases, 14 prostatic adenocarcinoma cases, 19 chronic abacterial prostatitis cases. Ninety-one benign prostatic hypertrophy patients could be evaluated at the three month follow-up date. Sixty-eight patients complained of severe obstructive symptoms and 23 had an indwelling catheter. Prostates were heated up to 42 +/- 0.5 degrees C during 60 minute long sessions, once or twice a week for five weeks. Local prostatic hyperthermia determined a marked amelioration of the clinical picture in 67% of patients who presented without an indwelling catheter. Sixteen patients (70%) were weaned off the catheter. Major complications were not encountered.

[Internal urinary derivation using an antegrade approach: indications, technic and results]

We report our experience in a group of patients with different pathological conditions and ureteral obstruction in whom placement of a double J stent had been attempted. Insertion of the stent beyond the site of obstruction by the retrograde technique could not be achieved and we therefore used the fluoroscopy-guided percutaneous approach. The indications, techniques and results are discussed.

Prostatic stenting for outflow obstruction

A series of 30 patients with outflow obstruction underwent treatment with prostatic stents. Most had retention of urine and were unfit for conventional surgery. The prostatic stent was readily inserted under local anaesthesia and successfully relieved obstruction in 80% of patients with acute retention. Minor problems were common but there were few major complications.

Self-retaining intraurethral stent: an alternative to long-term indwelling catheters or surgery in the treatment of prostatism

The self-retaining intraurethral coil is a device to stent the urethra in men who have severe urethral obstruction. It allows them to empty their bladders and still remain continent and sexually active. The device can be used in place of long-term indwelling catheters or as an alternative to surgery. During 1 year, we inserted the stent in 26 men who were poor operative risks. The treatment was successful in 20 (77%). All 20 were able to void satisfactorily. Four of the 20 resumed sexual activity, which previously had been prevented by indwelling catheters. Two patients who had delayed prostatic surgery because of fear of impotence were able to empty their bladders properly and to remain sexually active. Three patients subsequently had surgery, two after anticoagulant therapy could be stopped and one after renal function improved. No difficulties caused by the stent were encountered during surgery. Follow-up was for 2-12 months. Four patients who had had the stent in place for 12 months had no difficulties. In 16 of the 18 patients who had indwelling catheters and infected urine before insertion of the stent, sterilization of the urine was obtained after relatively short courses of antibiotic treatment. Short-term complications associated with the stent were incontinence or urinary retention. These were treated by repositioning the stent. Frequency of urination after insertion of the stent either disappeared spontaneously or was treated with anticholinergic drugs. In six patients, frequency was so severe that removal of the stent and insertion of an indwelling catheter were necessary. Slight to mild dysuria occurred immediately after surgery in all patients but eventually disappeared. Our experience suggests that the self-retaining intraurethral stent has considerable promise for the treatment of prostatic obstruction of the urethra.

The importance of separation of prostatic lobes in relief of prostatic obstruction by balloon catheter urethroplasty: studies in dogs and humans

We performed balloon urethroplasty in six older normal dogs and 10 patients with benign prostatic hypertrophy to establish the mechanism by which this technique results in relief of bladder outlet obstruction. Thirty-millimeter balloon catheters were used in both the animal and human studies. Autopsy studies showed disruption of the anterior prostatic commissure in four of the six dogs, disruption of both anterior and posterior commissures in one dog, and no disruption in the remaining dog. In all 10 patients, cystoscopy and urethrography showed disruption of the anterior commissure. Separation of the prostatic lobes by disruption of the prostatic commissures may be the most important mechanism by which balloon urethroplasty relieves urethral obstruction.

Interventional uroradiology

Major interventional uroradiologic techniques including percutaneous nephrostomy, vascular augmentation and reduction procedures, percutaneous cyst aspiration, chronic peritoneal dialysis catheter manipulation and urethroplasty are reviewed. A brief history of the development and techniques for performing these procedures are included. The results of clinical series are assessed and their role in patient management is addressed. The development of these procedures has had a significant impact on patient care by providing effective nonoperative therapy.

[Non-vascular interventional radiology nonvascular interventional radiology of the urinary tract]

Several kinds of nonvascular interventional radiology of the urinary tract are reviewed. Transurethral balloon dilation of the prostate (TU-DP) is a newly developed nonsurgical treatment for benign prostate hyperplasia, which is performed under local anesthesia with minimal morbidity and requires no hospitalization. The TUDP technique involves dilating the prostatic urethra and bladder neck to 75 F for 10 minutes under fluoroscopic control using a high-pressure dilating balloon. Long-term follow-up studies are required. Percutaneous nephrolithotomy (PNL) and transurethral ureterolithotomy (TUL) have signified a revolution in stone surgery of upper urinary tract. Indications for these treatments, endoscopic manipulation, complications and their clinical features are presented. The procedure of PNL consists of 3 steps, puncture for nephrostomy tract, tract dilation and stone removal. Among these steps the most important is the puncture and it should be effected through the calyx. During the operation, if there is too much bleeding, it can be discontinued at any time while keeping the track open. It is no longer necessary for the kidney to be free of stones at the end of the operation. TUL is performed with a rigid or flexible ureterorenoscope. Dilation of the ureteral orifice and the intramural ureter is necessary for passing the scopes. When they have been sufficiently dilated, the ureterorenoscope can be passed to the level of the renal pelvis through the urethra. Calculi have been removed successfully at a higher rate in lower ureter. Endopyelotomy may be performed safely as an initial procedure to correct congenital obstruction of the ureteropelvic junction. Recent advancements have permitted an approach to percutaneous resection for renal pelvic tumor in a solitary kidney or bilateral synchronous disease. There are great expectations for continuing important innovations in the field of interventional radiology.

Use of stents for treating obstruction of urinary outflow in patients unfit for surgery

Images

Balloon dilatation for prostatic obstruction. Long-term follow-up

Balloon dilatation of the prostatic urethra may improve the uroflow in patients with benign prostatic hypertrophy (BPH). In this study, patients were assigned blindly for balloon dilatation (5 men) or observation (3 men). A 36F balloon was inflated in the prostatic urethra with local anesthesia and fluoroscopic guidance for thirty minutes. The effects of the procedure were monitored during a two-year follow-up period. Two of the treated patients had improvement in uroflow and experienced stabilization of clinical symptoms. Two had no significant change in uroflow and required prostatectomy within the observation period. One required prostatectomy soon after dilatation. One of the 3 patients in the control group required prostatectomy in the two-year follow-up period and the other 2 continue to have obstructive symptoms. Although dilatation of the prostatic urethra by balloon may relieve some patients of urinary outflow obstruction due to BPH, it appears that a 36F balloon dilator does not produce dramatic or consistent results, and the effects of larger balloons should be evaluated.

[Pneumatic dilatation of urethral stenosis]

We report on a series of 32 patients with urethral strictures of different etiology, site, and morphology that were submitted to treatment by balloon dilatation. The results achieved corroborate the usefulness of this procedure. It is easy to perform and there are no complications. Furthermore, it affords economic advantages since it can be performed with simple local anesthesia on an outpatient basis. For all the foregoing reasons, we believe that balloon dilatation is a useful procedure in the treatment of urethral strictures that permits raising the success rate in well-selected cases of urethral strictures untreated previously by other surgical procedures. Balloon dilatation and endoscopic internal urethrotomy are the procedures of choice in the treatment of a vast majority of strictures.

Pleural effusion and hydronephrosis in a newborn

While the association of obstructive uropathy with ascites has been known since 1863, and with pleural effusion since 1954, the latter combination remains rare. This case report describes a male newborn with a massive left pleural effusion that was caused by same-sided hydronephrosis from obstructing posterior urethral valves. The effusion disappeared within a few days after adequate urinary drainage was established, and the infant was remained well since the abnormal urethral valves were fulgurated cystoscopically. Review of the clinical and experimental literature reveals no consensus about how pleural fluid accumulates in the presence of obstructive uropathy, and this neonate showed a direct inverse relation between the amount of pleural fluid drainage and urinary output via catheter. Hydronephrosis should be considered diagnostically when a newborn has a pleural effusion that is otherwise unexplained.

The biphasic nature of renal functional recovery following relief of chronic obstructive uropathy

Twenty-one patients with chronic obstructive uropathy due to high pressure chronic retention of urine underwent renal functional assessment both during the period of obstruction and repeatedly up to 3 months following its relief. Glomerular filtration rate (GFR) was determined using clearance of 99mTc-DTPA and iohexol. Creatinine, water, urea and electrolyte excretion was assessed from timed urine collections. Excretion of water, urea and electrolyte was normal during obstruction but increased dramatically immediately following relief (e.g. sodium 110 to 234 mmol/24 h). Values returned to normal by 2 weeks (sodium excretion 148 mmol/24 h). No further significant changes occurred up to 3 months. Mean 99mTc-DTPA and iohexol clearances during obstruction were 59.0 and 50.5 ml/min respectively. Following relief of obstruction, no significant improvement occurred at 2 weeks but did at 3 months (mean = 68.4 and 55.7 ml/min). Mean creatinine clearance during obstruction was 32.5 ml/min. This improved 2 days following relief to 46 ml/min. No further improvement was seen until 3 months (mean = 57.3 ml/min). It was concluded that recovery of renal function from obstructive injury occurs in two phases, an early tubular phase lasting up to 2 weeks and a later, predominantly glomerular phase, between 2 weeks and 3 months. There is some disparity between creatinine clearance and more accurate measurements of GFR which may be explained by tubular excretion of creatinine in the early phase of recovery.

[Transluminal urethroplasty. Preliminary experience in 15 cases]

Thirteen patients with urethral stenoses of different etiopathology underwent TUP with an angioplasty balloon catheter. At follow-up, more than 10 months later, 8 out of 10 patients had normal urinary function. Excluding cases of urethral compression due to prostatic hyperplasia, 90% of the stenoses were successfully dilated. The gradualness of the dilatation, the application of a Foley catheter to maintain the dilatation obtained and the prevention of urinary infections are important factors for the success of this method.

Alternative treatment of prostatic urethral obstruction secondary to benign prostatic hypertrophy. Non-surgical balloon catheter prostatic dilatation

Benign prostatic hypertrophy (BPH) produces symptoms that currently can only be treated surgically either by open or endoscopic prostatectomy. We have undertaken animal (1) and human studies to determine if invasive radiologic techniques utilizing balloon catheters could be applied to the treatment of this common ailment. We report a series of twelve patients treated by retrograde transurethral balloon catheter prostatic dilatation. The procedure is performed using topical anesthesia with a specially designed balloon catheter (Medi-Tech, Inc.). The procedure is done on an outpatient basis and is completed within approximately 15 minutes. Relatively long-term results have resulted in persistent relief of symptoms. No complications have been encountered. We anticipate that balloon dilatation of the prostatic urethra will have a major impact on the treatment of BPH based on the promising preliminary results. Transurethral resection of the prostate (TURP) is associated with moderate morbidity and significant cost which can be reduced by the proposed procedure.

Fogarty balloon catheter ablation of neonatal posterior urethral valves

We describe a technique to ablate posterior urethral valves with a Fogarty balloon catheter. This technique has been used for 14 years in 10 cases with a good result in 9. Fogarty balloon catheter ablation of posterior urethral valves would seem to be particularly applicable to the small neonate with a vulnerable anterior urethra.

Urethral disease and interventional cystourethrography

The innovation of balloon dilatation of urethral stricture and prostatic hypertrophy is a major contribution to interventional radiology. The procedure involves minimal trauma, produces immediate relief of symptoms, and probably results in less frequent and less difficult redilatations. The sparsity of reports in the literature on this subject reflects the reluctance of urologists to refer patients for balloon dilatation of urethral strictures. Every effort must be made by the radiologist to impress the urologist with the value of this procedure, which would eliminate the production of false passages and likely reduce the recurrence rate. Initial results with this procedure are encouraging, but larger series are required and long-term follow-up is necessary for evaluation of cure rate, rate of recurrence, and possible complications.

Capsular influence on benign prostatic hyperplasia

Attention in both research and treatment has been directed primarily at the BPH, that is the periurethral growth rather than to the surrounding prostate. If this growth could be prevented, or if, once developed, the growth process could be reversed, the problem of prostatic obstruction would be solved. At present, no medical solution acceptable to the patient is apparent. Since the capsule assumes such a dominant role in obstruction, equal attention should be paid in laboratory and clinical research on means for reversing the activities of this compressed prostate on BPH and the outflow tract.

[Fetal megacystis--prenatal diagnosis and attempt at therapy]

Dilatations of the fetal urinary tract are suspect for obstructions. An extremely dilated bladder may also point to an innervation disorder. In the here presented case a very rare disease is the cause for the dilatation of the fetal bladder, the Megacystis-Microcolon-Hypoperistalsis-Syndrome. No mature ganglionic cells are detectable in the bladder wall histologically. Up to now eight cases have been reported, all female neonates died within the first days after birth. Our presented child - also a female - is now more than one year old, but artificial feeding is still necessary.

Unsuspected proximal urethral obstruction in young and middle-aged men

Proximal urethral obstruction, a common cause of prostatism in young and middle-aged men, often is misdiagnosed as prostatitis, neurogenic bladder or a psychogenic voiding disorder. Simple urodynamic studies (uroflowmetry and cystometry) do not distinguish a poor flow owing to bladder neck obstruction from that caused by poor detrusor contractility in these patients. Only the simultaneous measurement of detrusor pressure and uroflowmetry can make this distinction. A total of 23 patients with unsuspected proximal urethral obstruction underwent synchronous video-pressure-flow electromyography studies, and were treated and followed for a minimum of 1 year. Treatment by transurethral prostatic resection or bladder neck incision almost always was curative but alpha-adrenoceptor blocking agents have not been effective. All patients who underwent transurethral prostatic resection or bladder neck incision at the 5 and 7 o'clock positions have had retrograde ejaculation but both patients who underwent unilateral bladder neck incision reported antegrade ejaculation.

Nonsurgical management of canine obstructive urolithopathy

Obstruction to urine outflow is a common complication of urolithiasis. However, varying degrees of recovery of renal function may occur following examination of the cause of obstruction. Therefore, in the absence of conclusive evidence of irreversible dysfunction, one should consider efforts to decompress the urinary tract and to eliminate the cause of obstruction. Nonsurgical methods that may be used for management of obstructive urolithiasis include cystocentesis, palpation, urohydropropulsion, and catheterization.

A possible prenatal evaluation of renal function by amino acid analysis on fetal urine

Intrauterine treatment of 4 fetuses with urethral obstruction was attempted in the third trimester of pregnancy. The fetuses displayed varying sonographic findings including pyelectasis, caliectasis, hydroureter, bladder dilatation, ascites, hydrops, missing kidneys and oligohydramnios. Ultrasonically guided aspiration from the dilated structures was carried out to relieve pressure on the kidney parenchyme and to collect fluid samples for diagnostic purposes. Amino acid concentrations in the fetal urine showed a pattern similar to plasma in 2 fetuses, a pattern almost like urine in 1 fetus and an intermediate pattern in the 4th fetus. Only the fetus with normal amino acid concentrations in the urine survived: the other 3 died in uremia shortly after birth. In 3 cases cells from the aspirated urine were cultured and used for chromosome analysis. The cell cultures grew fast and karyotyping was possible within 1 week. In 2 fetuses an intrauterine catheter was inserted to drain the kidney permanently into the amniotic cavity. In the first case the catheter was displaced to the fetal abdomen after some days of successful drainage. In the second case the catheter tore the placenta, and the child had to be delivered immediately.