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Banerjee I, Smith NA, Katz JE, Gokhale A, Shah R, Shah HN. Simultaneous Holmium Laser Enucleation of Prostate with Removal of the Permanent Prostatic Urethral Stent Using the High-Power Holmium Laser: Technique in Two Cases and Review of the Literature. J Endourol Case Rep 2020; 6:438-441. [PMID: 33457695 DOI: 10.1089/cren.2020.0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Although the prostatic urethral stents are no longer used in the United States for treatment of prostatomegaly, urologists will encounter patients with complications of previously placed permanent prostatic stents. We report two cases of persistent bothersome lower urinary tract symptoms (LUTS) after prostatic stent placement treated with simultaneous holmium laser enucleation of prostate (HoLEP) with endoscopic removal of the prostatic urethral stent using high-power holmium laser. We also reviewed the literature regarding the removal of prostatic stents with holmium laser combined with surgical management of benign prostatic hyperplasia. Case Presentation: A 71-year-old man who presented with LUTS, recurrent gross hematuria, and urinary infection, which developed after placement of a prostatic stent 10 years prior for urinary retention secondary to prostatomegaly (80 g). He underwent combined HoLEP with endoscopic removal of the prostatic stent using 100 W holmium laser at a power setting of 2 J and 30 Hz. The surgical steps comprised fragmentation of the stent in situ by making incisions at 5, 7, and 12 o'clock positions followed by enucleation of the prostate. The stent was then separated from enucleated tissue in the urinary bladder. The remaining prostate adenoma was then morcellated and removed. The patient remained asymptomatic at 10-year follow-up. Another patient was 62-year-old man who developed recurrence of bothersome LUTS, 1 year after placement a prostatic stent for urinary retention. On investigation his prostate was 105 g and stent showed partial migration in the bladder with overlying calcification. HoLEP and stent removal was performed in a manner similar to the first patient. This patient also remained asymptomatic at a 1-year follow-up. Conclusion: Combined HoLEP with removal of a prostatic urethral stent using a high-power holmium laser is safe and effective with long-term durable outcome.
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Affiliation(s)
- Indraneel Banerjee
- Department of Urology, Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | - Nicholas Anthony Smith
- Department of Urology, Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | - Jonathan E Katz
- Department of Urology, Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | | | - Rashmi Shah
- Urolap Superspeciality Clinic and S. L. Raheja (Fortis Associate Hospital) Mumbai, Mumbai, India
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Boysen WR, Bales GT. The Role of Chemical Sphincterotomy with Urethral Botulinum Toxin Injection in Patients with Neurogenic and Non-neurogenic Failure to Empty. CURRENT BLADDER DYSFUNCTION REPORTS 2018. [DOI: 10.1007/s11884-018-0478-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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3
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Baker N, Tong C, Simhan J. Reconstructive Management Options of Delayed Complications Following Bladder Outlet Surgery. Curr Urol Rep 2017; 18:27. [PMID: 28247326 DOI: 10.1007/s11934-017-0678-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Technological advancements in urologic endoscopy within the last decades have improved outcomes following bladder outlet reduction surgery while minimizing risks of short- and intermediate-term complications. This review aims to examine late complications of endoscopic reduction of the prostate and the various treatment options available. RECENT FINDINGS Urinary incontinence, ejaculatory dysfunction, urethral strictures, bladder neck contractures, and fistula formations are the most common delayed complications following bladder outlet reduction surgery. Evaluation of these complications typically involves a combination of endoscopic examination, urodynamic findings, pelvic imaging, and review of pre-existing symptoms. Treatment options range from conservative measures such as pelvic floor muscle therapy to complex reconstructive procedures including anti-incontinence surgery, urethral reconstruction, and permanent urinary diversion. Although rare, late complications of bladder outlet reduction surgery are important to recognize in order to manage appropriately. Careful evaluation involving multiple diagnostic modalities with consideration for referral to a dedicated reconstructive urologist may be warranted in complex cases.
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Affiliation(s)
- Nora Baker
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Carmen Tong
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jay Simhan
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA. .,Urologic Trauma, Reconstruction and Prosthetics, Einstein Healthcare Network, Temple Health and the Fox Chase Cancer Center, 1200 Tabor Road, Moss/3 Sley, Philadelphia, PA, 19141, USA.
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Christidis D, McGrath S, Perera M, Manning T, Bolton D, Lawrentschuk N. Minimally invasive surgical therapies for benign prostatic hypertrophy: The rise in minimally invasive surgical therapies. Prostate Int 2017; 5:41-46. [PMID: 28593165 PMCID: PMC5448728 DOI: 10.1016/j.prnil.2017.01.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/27/2022] Open
Abstract
The prevalence of benign prostatic hypertrophy (BPH) causing bothersome lower urinary tract symptoms increases with our ageing population. Treatment of BPH traditionally begins with medical therapy and surgical intervention is then considered for those whose symptoms progress despite treatment. Minimally invasive surgical therapies have been developed as an intermediary in the treatment of BPH with the aim of decreasing the invasiveness of interventions. These therapies also aim to reduce morbidity and dysfunction related to invasive surgical procedures. Multiple treatment options exist in this group including mechanical and thermo-ablative strategies. Emerging therapies utilizing differing technologies range from the established to the experimental. We review the current literature related to these minimally invasive therapies and the evidence of their effectiveness in treating BPH. The role of minimally invasive surgical therapies in the treatment of BPH is still yet to be strongly defined. Given the experimental nature of many of the modalities, further study is required prior to their recommendation as alternatives to invasive surgical therapy. More mature evidence is required for the analysis of durability of effect of these therapies to make robust conclusions of their effectiveness.
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Affiliation(s)
- Daniel Christidis
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Young Urology Researchers Organization (YURO), Melbourne, Australia
| | - Shannon McGrath
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Young Urology Researchers Organization (YURO), Melbourne, Australia
| | - Marlon Perera
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Young Urology Researchers Organization (YURO), Melbourne, Australia
| | - Todd Manning
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Young Urology Researchers Organization (YURO), Melbourne, Australia
| | - Damien Bolton
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Olivia Newton-John Cancer Research Institute, Heidelberg, Melbourne, Australia
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Stoffel JT. Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies. Transl Androl Urol 2016; 5:127-35. [PMID: 26904418 PMCID: PMC4739973 DOI: 10.3978/j.issn.2223-4683.2016.01.08] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Detrusor sphincter dyssynergia (DSD) is the urodynamic description of bladder outlet obstruction from detrusor muscle contraction with concomitant involuntary urethral sphincter activation. DSD is associated with neurologic conditions such as spinal cord injury, multiple sclerosis, and spina bifida and some of these neurogenic bladder patients with DSD may be at risk for autonomic dysreflexia, recurrent urinary tract infections, or upper tract compromise if the condition is not followed and treated appropriately. It is diagnosed most commonly during the voiding phase of urodynamic studies using EMG recordings and voiding cystourethrograms, although urethral pressure monitoring could also potentially be used. DSD can be sub-classified as either continuous or intermittent, although adoption of this terminology is not widespread. There are few validated oral pharmacologic treatment options for this condition but transurethral botulinum toxin injection have shown temporary efficacy in reducing bladder outlet obstruction. Urinary sphincterotomy has also demonstrated reproducible long term benefits in several studies, but the morbidity associated with this procedure can be high.
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Affiliation(s)
- John T Stoffel
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Management of the Detrusor Sphincter Dyssynergia. CURRENT BLADDER DYSFUNCTION REPORTS 2013. [DOI: 10.1007/s11884-013-0182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Polguer T, Boissier R, Gaillet S, Lenne Aurier K, Savoie PH, Lechevallier E, Coulange C, Karsenty G. [Treatment of detrusor-striated sphincter dyssynergia with permanent nitinol urethral stent: results after a minimum follow-up of 2 years]. Prog Urol 2012. [PMID: 23182120 DOI: 10.1016/j.purol.2012.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to assess the outcomes of nitinol permanent urethral stents used in detrusor-striated sphincter dyssynergia (DSD) treatment on male patients with a spinal cord injury. MATERIALS We investigated retrospectively all patients treated from 2004 to 2012. A total of 22 patients were included, with an age ranging from 22 to 76 years old. The DSD syndrome was due to spinal cord injury (18) or various spinal cord diseases (four) and treated with a nitinol urethral stent (11 Ultraflex(®) and 11 Mémotherm(®)). Every patient had an urodynamical study. The follow-up reached at least 2 years. RESULTS The mean follow-up was 56 months (± 14). Complementary procedures after stenting included: five stent prolongation or displacement (mean interval 7.6 months), six bladder neck incisions (12.2 months), three urethrotomy (42 months), ten obstruction treated by laser (47.3 months). Eight patients had a change of their urinary pattern: four underwent ileal conduit diversion, one had a continent urinary diversion, one chose self intermittent catheterization, two were under indwelling catheterization waiting for another treatment. Stent retrieval was either harmful or impossible for four of them. Three patients were free of complementary procedures. CONCLUSIONS Nitinol urethral stent was an effective treatment initially. However, by the third year, urethral stenosis and hypertrophic growth of the urethral mucosa usually require iterative endoscopic procedures (0.31 per patient per year). Patients treated with permanent uretral stent deserve a yearly endoscopic follow-up. Safety and effectiveness of permanent uretral stent compared to surgical sphincterotomy to treat DSD are discussed.
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Affiliation(s)
- T Polguer
- Service d'urologie, hôpital Gabriel-Montpied, université d'Auvergne, CHU de Clermont-Ferrand, 58, rue Montalemberg, 63000 Clermont-Ferrand, France
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9
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Tahmaz L, Cem Irkilata H, Simsek K, Zor M, Basal S, Ay H. Urethral Stripping Caused by Stent Removal and Its Successful Treatment With Hyperbaric Oxygen Therapy: A Case Report. Kaohsiung J Med Sci 2009; 25:334-7. [DOI: 10.1016/s1607-551x(09)70524-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Eisenberg ML, Elliott SP, McAninch JW. Management of restenosis after urethral stent placement. J Urol 2008; 179:991-5. [PMID: 18206915 DOI: 10.1016/j.juro.2007.10.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Indexed: 11/19/2022]
Abstract
PURPOSE We describe our experience with the management of restricture after urethral stent placement, including endoscopic and open surgical treatment. MATERIALS AND METHODS We surveyed our prospectively collected database for patients with restenosis after urethral stent insertion. We reviewed patient age, comorbidities, indications for stent placement, restricture length, management of restricture, postoperative complications and the further restenosis rate. RESULTS Overall we have treated 22 patients with failed urethral stents with a median followup of 30 months (range 1 to 96). All stents were initially placed for urethral stricture management. Stricture etiology included prostate cancer therapy in 9 cases, idiopathic causes in 6, urethral instrumentation in 2, trauma in 2, simple prostatectomy in 2 and gender reassignment/phalloplasty in 1. Ten patients had anterior urethral stricture, 11 had posterior stricture and 1 patient had each type. Of the 22 patients with stenosis after stent placement 13 underwent urethroplasty. Of the 18 patients with indwelling stents at treatment the stent was removed in 8 intraoperatively and in 10 the stent was left in situ. Ten of the 11 anterior strictures were treated with urethroplasty. Only 4 of the 12 posterior strictures were treated with urethroplasty, while 8 were managed endoscopically. Our overall success rate for treatment after stent failure was 67% (8 of 12 cases) for posterior urethral strictures and 82% (9 of 11) for anterior strictures. CONCLUSIONS Urethral stent failure requires complex intervention. A failed posterior urethral stent can often be managed endoscopically. Conversely we have managed failed anterior urethral stents by urethroplasty.
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Affiliation(s)
- Michael L Eisenberg
- University of California-San Francisco and San Francisco General Hospital, San Francisco, California 94110, USA
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11
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Gamé X, Chartier-Kastler E, Ayoub N, Even-Schneider A, Richard F, Denys P. Outcome after treatment of detrusor–sphincter dyssynergia by temporary stent. Spinal Cord 2007; 46:74-7. [PMID: 17471293 DOI: 10.1038/sj.sc.3102069] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent. MATERIALS AND METHODS Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case. RESULTS The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD). CONCLUSION After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.
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Affiliation(s)
- X Gamé
- Service d'Urologie, Groupe Hospitalier Pitié-Salpétrière, Paris, France
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12
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Ayoub N, Chartier-Kastler E, Ruffion A. Chapitre B-3 A - Traitement chirurgical des dysfonctions neurologiques des sphincters urinaires. Prog Urol 2007; 17:515-28. [PMID: 17622084 DOI: 10.1016/s1166-7087(07)92362-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The treatment of neurogenic detrusor-sphincter dyssynergia is primarily medical (drugs and catheterization). Some patients may not be eligible for or fail to respond to these treatment options and endoscopic sphincterotomy or permanent prosthesis may be indicated. In this article, the authors review the indications, results and contraindications of these various treatments.
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Affiliation(s)
- N Ayoub
- Service d'urologie, Hopital de l'Hôtel Dieu, Beyrouth, Liban
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13
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Crisóstomo V, Song HY, Maynar M, Sun F, Soria F, Lima JR, Yoon CJ, Usón-Gargallo J. Evaluation of the Effects of Temporary Covered Nitinol Stent Placement in the Prostatic Urethra: Short-Term Study in the Canine Model. Cardiovasc Intervent Radiol 2007; 30:731-7. [PMID: 17436035 DOI: 10.1007/s00270-007-9006-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the effect of temporary stent placement on the canine prostatic urethra. METHODS Retrievable PTFE-covered nitinol stents were placed in the prostatic urethras of 8 beagle dogs under fluoroscopic guidance. Retrograde urethrography was obtained before and after stenting. Retrograde urethrography and endoscopy were performed 1 and 2 months after deployment. The endoscopic degree of hyperplasia was rated on a scale of 0 to 4 (0 = absence, 4 = occlusion). On day 60, stents were removed and urethrography was performed immediately before euthanasia. Pathologic analysis was performed to determine the degree of glandular atrophy, periurethral fibrosis, and urethral dilation. RESULTS Stent deployment was technically successful in 7 animals, and failed in 1 dog due to a narrow urethral lumen. Complete migration was seen in 2 animals at 1 month, and an additional stent was deployed. On day 30, endoscopy showed slight hyperplasia (grade 1) in 3 animals. On day 60, moderate hyperplasia (grade 2) was evidenced in 4 cases. No impairment of urinary flow was seen during follow-up. Retrieval was technically easy to perform, and was successful in all dogs. The major histologic findings were chronic inflammatory cell infiltrates; prostate glandular atrophy, with a mean value of 1.86 (SD 0.90); periurethral fibrosis, with a mean ratio of 29.37 (SD 10.41); and dilatation of the prostatic urethra, with a mean ratio of 6.75 (SD 3.22). CONCLUSION Temporary prostatic stent placement in dogs is safe and feasible, causing marked enlargement of the prostatic urethral lumen. Retrievable covered stents may therefore be an option for bladder outlet obstruction management in men.
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Affiliation(s)
- Verónica Crisóstomo
- Minimally Invasive Surgery Center, Avda. de la Universidad, s/n Campus Universitario, 10071, Cáceres, Spain.
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Seoane-Rodríguez S, Sánchez R-Losada J, Montoto-Marqués A, Salvador-de la Barrera S, Ferreiro-Velasco ME, Alvarez-Castelo L, Balsa-Mosquera B, Rodríguez-Sotillo A. Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia. Spinal Cord 2007; 45:621-6. [PMID: 17211463 DOI: 10.1038/sj.sc.3102011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES To assess in the long-term clinical and urodynamic results of intraurethral stents in a group of patients with spinal cord injury. SETTING Spinal Cord Injury Unit, Juan Canalejo Hospital, A Coruña, Spain. METHODS Forty-seven consecutive male patients were studied from 1993 to 2002. All of them suffered from hyperreflexia with detrusor-sphincter dyssynergia (DSD) owing to spinal cord injury, and were treated by means of the placement of an intraurethral stent at the external sphincter. RESULTS After surgery, significant decreases in all the parameters studied were observed. The number of patients with symptoms of urinary tract infection decreased by 25% (P<0.031). Post-void residual urine volume experienced an average decrease of 224.3 cm(3) (P=0.001). Episodes of dysreflexia decreased from 35.1 to 16.2% (P=0.039). The urodynamic study showed an average reduction of 44.36 cm H(2)O in the maximum detrusor pressure (P<0.0001). Complications in the upper urinary tract descended from 46.8 to 23.4% after placing the stent (P=0.013). The most frequent stent complication was displacement, followed by stenosis, lithiasis and intraprosthetic calcification. In all, 8.5% required the stent removal. CONCLUSIONS Intraurethral stent is a good choice for the long-term management of DSD in spinal cord-injured patients, even in those who had been previously submitted to prior sphincterotomy. It has the advantage of being a potentially reversible procedure, so patients prefer it to more invasive therapies such as sphincterotomy.
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Tseng KF, Tai HL, Chang CP. Case Report: Endoscopic Removal of Memotherm Urethral Stent with Diode Laser. J Endourol 2007; 21:100-2. [PMID: 17263619 DOI: 10.1089/end.2006.0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An 81-year-old patient with benign prostatic hyperplasia with a history of acute myocardial infarction had undergone Memotherm urethral-stent placement because acute urinary retention 5 years previously. The stent protruded over the bladder neck without epithelialization and had recently become encrusted with vesical calculi. We used a diode laser to cut the stent and simultaneously performed laser prostatectomy. After the procedure, the patient was well and able to void easily.
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Affiliation(s)
- Kuan-Fu Tseng
- Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
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Ahmed HU, Shergill IS, Arya M, Shah PJR. Management of detrusor-external sphincter dyssynergia. ACTA ACUST UNITED AC 2006; 3:368-80. [PMID: 16835625 DOI: 10.1038/ncpuro0521] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 04/27/2006] [Indexed: 11/09/2022]
Abstract
Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. The mainstay of treatment is the use of antimuscarinic medication and catheterization, but in those for whom this is not possible external sphincterotomy has been the traditional management route. External sphincterotomy, however, is associated with significant risks, including hemorrhage, erectile dysfunction and the need for repeat procedures, and over the last decade alternatives have been investigated, such as urethral stents and botulinum toxin injection. We present a review of DSD, including the current management strategies and prospects for future treatment.
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Affiliation(s)
- Hashim U Ahmed
- Institute of Urology and Nephrology, University College London, London, UK
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Mehta SS, Tophill PR. Memokath® stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: The Princess Royal Spinal Injuries Unit 10-year experience. Spinal Cord 2005; 44:1-6. [PMID: 16044169 DOI: 10.1038/sj.sc.3101800] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Medical records review. OBJECTIVE To assess the effectiveness of the Memokath (Engineers and Doctors A/S, Denmark) thermosensitive stent as a 'nondestructive' means of reducing bladder outlet resistance by treating detrusor sphincter dyssynergia (DSD) of neurogenic bladder dysfunction associated with spinal cord injury. SETTING Spinal Injuries Unit, Sheffield, England. METHODS A medical records review was performed to examine our experience of Memokaths over the last 10 years. During this time, 29 patients with spinal cord injury (17 tetraplegic and 12 paraplegic) underwent stenting of the external urethral sphincter either for prevention of dysreflexic symptoms, high residual urine volumes and subsequent urinary tract infection (UTI) or for protection of the upper tracts. RESULTS A total of 33 stents were inserted into 29 men (25-77 years) with suprasacral spinal cord injury. Initial results showed that the Memokath was effective in almost all for relief of dysreflexic symptoms and elimination of DSD on pressure flow urodynamics. However, to date, 30 of the 33 stents have been removed. The overall mean working life of the Memokath was 21 months. Four stents were removed electively and 23 for complications, which included stent migration (seven) and blockage (14). Single-ended stents were more prone to migration, which was rare after 1 year (1-13 months, median 3 months, mean 5.5 months). Stent blockage by encrustation or prostatic ingrowth did not occur before 12 months (12-45 months, median 30, mean 27.9 months). CONCLUSIONS In selected patients, temporary, thermo-expandable (Memokath) stents are effective in the treatment of DSD. The 'working life' of a Memokath stent is 21 months; however, complications do occur which may necessitate removal. Our overall experience with Memokath stents was disappointing. In future, Memokath stents will only be inserted after careful consideration in patients with prior 'failed' transurethral sphincterotomy or with caution in patients suitable for reconstructive surgery.
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Affiliation(s)
- S S Mehta
- Royal Hallamshire Hospital, Sheffield, UK
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Hussain M, Greenwell TJ, Shah J, Mundy A. Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int 2004; 94:1037-9. [PMID: 15541123 DOI: 10.1111/j.1464-410x.2004.05100.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.
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Parsons JK, Wright EJ. Extraction of UroLume endoprostheses with one-stage urethral reconstruction. Urology 2004; 64:582-4. [PMID: 15351598 DOI: 10.1016/j.urology.2004.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Accepted: 04/20/2004] [Indexed: 11/25/2022]
Abstract
We describe a technique for transperineal excision of UroLume endoprostheses with one-stage urethral reconstruction. We have used this technique in 3 patients with occluded urethral stents placed for bulbar stricture disease. All patients experienced acceptable outcomes.
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Affiliation(s)
- J Kellogg Parsons
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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Rapp DE, Laven BA, Steinberg GD, Gerber GS. Percutaneous Placement of Permanent Metal Stents for Treatment of Ureteroenteric Anastomotic Strictures. J Endourol 2004; 18:677-81. [PMID: 15597662 DOI: 10.1089/end.2004.18.677] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.
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Affiliation(s)
- David E Rapp
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois 60637, USA
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21
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Abstract
PURPOSE In recent years there has been tremendous excitement over the use of botulinum neurotoxin (BTX) to treat various urethral and bladder dysfunctions. BTX is the most potent, naturally occurring toxin known to mankind. Why, then, would a urologist want to use this agent to poison the bladder or urethral sphincter? MATERIALS AND METHODS We reviewed the recent literature on the mechanisms underlying the effects of BTX treatment and discuss current use of this agent within the urological community, as well as provide perspective on future targets of BTX. The information was gathered from MEDLINE, abstracts from recent urological meetings and personal experience. RESULTS Injection of BTX appears to have a positive therapeutic effect in multiple urological conditions, including detrusor hyperreflexia and detrusor external sphincter dyssynergia, and nonneurogenic conditions such as pelvic floor spasticity, refractory overactive bladder and, possibly, benign prostatic hyperplasia. Interstitial cystitis may even be potentially helped with bladder BTX injection. CONCLUSIONS Botulinum toxin is a novel and promising treatment for a variety of lower urinary tract dysfunctions. The basic science behind its mechanism of action and physiology, and published clinical results are impressive. However, since application of BTX in the lower urinary tract has not been approved by the Food and Drug Administration, caution should be used until future properly designed, multicenter randomized studies are completed to assess the safety and efficacy of BTX in urological diseases.
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Affiliation(s)
- Christopher P Smith
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
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Cimentepe E, Unsal A, Koc A, Bayrak O, Balbay MD. Temporary urethral stenting for membranous urethral stricture helps complete healing without compromising continence. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2004; 38:521-2. [PMID: 15841790 DOI: 10.1080/00365590410018710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
We report the case of a patient with a recurrent membranous urethral stricture who was treated with temporary implantation of a UroLume endoprosthesis and recovered completely, without any sphincteric insufficiency or stricture recurrence, during a 1-year follow-up period.
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Affiliation(s)
- Ersin Cimentepe
- Department of Urology, School of Medicine, Fatih University, Ankara, Turkey.
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Abstract
PURPOSE We examined the timing, causes and results of the explantation of UroLume (American Medical Systems, Minnetonka, Minnesota) urethral stents. MATERIALS AND METHODS The North American Study Group enrolled 465 patients in a trial of UroLume stent placement, including 69 (14.8% of the series) who required removal of a total of 73 stents (15.6% of stents) in 7 years. The time of explantation, reason for stent removal and local histological findings were determined from patient charts and reviewed in relation to the indication for stent placement. RESULTS In patients treated for bladder outlet obstruction secondary to benign prostatic hyperplasia 23% of the stents were removed, as were 5% of those implanted in patients with bulbar urethral stricture and 22% of those in patients with detrusor-sphincter dyssynergia (see figure). Of the explantations 43.8% were done during year 1. Migration and/or inappropriate placement was the cause in 38.4% of cases. The most common stent site tissue finding was focal inflammation with a hyperplastic tissue response. Stent specific malignant changes were not observed. Stent removal was feasible with no sequelae. CONCLUSIONS When used appropriately, the UroLume endoprosthesis has a low incidence of failure. Stent removal is technically feasible and options are available for subsequent therapy. Local tissue reaction is minimal.
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Affiliation(s)
- Darshan K Shah
- Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York, USA
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Reynard JM, Vass J, Sullivan ME, Mamas M. Sphincterotomy and the treatment of detrusor-sphincter dyssynergia: current status, future prospects. Spinal Cord 2003; 41:1-11. [PMID: 12494314 DOI: 10.1038/sj.sc.3101378] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Literature review of current treatment options for detrusor-sphincter dyssynergia (DSD) in spinal cord injury. OBJECTIVES To review the outcomes and complications associated with external sphincterotomy and to summarise the results and complications of alternative treatment options for detrusor-sphincter dyssynergia in spinal cord injury. In addition, we propose a potential alternative future drug treatment for external sphincter dyssynergia based upon recent research on the neuropharmacology of the external urethral sphincter. SETTING The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHODS Medline search from 1966 to 2002 using the words 'external sphincterotomy', 'detrusor-sphincter dyssynergia' and 'neurogenic bladder combined with surgery'. RESULTS While external sphincterotomy is an effective treatment for DSD, a significant number of men following this procedure continue to have high intrarenal pressures, recurrent urinary infection or troublesome autonomic dysreflexia and a worryingly high proportion demonstrate persistently raised leak point pressures, putting them at subsequent risk of renal damage. Alternative treatments for external sphincter dyssynergia include urethral stents and balloon dilatation, both of which are effective. However, over the long term stents can undergo encrustation and there remains a definite risk of stent migration necessitating stent removal or replacement. Balloon dilatation of the external sphincter is associated with a risk of subsequent stricture formation. Intraurethral Botulinum A toxin seems to be effective though there have been no large randomised studies comparing it against placebo. However, it is not a durable treatment option and it has not found a common place in the treatment of DSD. There is now a considerable amount of experimental data from both animal and human studies to suggest that nitric oxide (NO) is an important physiological inhibitory neurotransmitter in the urethral sphincter, mediating relaxation of the external urethral sphincter. The potential role of sphincter NO augmentation for treatment of DSD is discussed. CONCLUSION External sphincterotomy remains the mainstay of treatment for urodynamically significant detrusor-sphincter dyssynergia, but in recent years a number of effective, alternative treatment options have become available. While at present there is no effective systemic drug treatment, recent research into external sphincter neuropharmacology suggests that systemic or topical augmentation of external sphincter NO may provide an effective method for lowering sphincter pressure.
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Affiliation(s)
- J M Reynard
- The National Spinal Injuries Centre, Stoke Mandeville Hospital, UK
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Hamid R, Arya M, Patel HRH, Shah PJR. The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up. BJU Int 2003; 91:51-3. [PMID: 12614250 DOI: 10.1046/j.1464-410x.2003.04009.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients. PATIENTS AND METHODS Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying. RESULTS Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. CONCLUSION Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.
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Affiliation(s)
- R Hamid
- Spinal Injuries Unit, Royal International Orthopaedic Hospital, Stanmore, UK.
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Affiliation(s)
- TRACEY S. WILSON
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
| | - GARY E. LEMACK
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
| | - ROGER R. DMOCHOWSKI
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
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Zannoud M, Ghadouane M, Alami M, Jira H, Kasmaoui EH, Abbar M. [Detrusor-sphincter dyssynergia: four case reports and literature review]. ANNALES D'UROLOGIE 2002; 36:132-7. [PMID: 11969047 DOI: 10.1016/s0003-4401(01)00086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
UNLABELLED Detrusor-sphincter dyssynergia is responsible for major impairment and is factor for social and professional activity repercussions. METHODS We have studied the clinical and urodynamic finding in four patients (two men and two women) with detrusor-sphincter dyssynergia. Mean age is 36 years (26-44 years). Dyssynergia was secondary to tuberculosis meningitis in one case, surgery for rectal adenocarcinoma in one case, tight vertebral canal in one case and in one case the cause is indeterminate. The detrusor-sphincter dyssynergia were treated by autocatheterism in two cases, antibiotherapy antituberculosis associated with an anticholinergic drugs in one case and by alpha-blockers agent in another. RESULTS Quasi-complete salvage of the motor deficit and the dysfonctional voiding in a patient treated by antibiotherapy antituberculosis associated with an anticholinergic drugs. As well, maid evolution in patient treated by alpha-blockers agent and who practice self catheterization. CONCLUSION Optimal treatment is unknown, and the existence of several cures indicated the limit of all therapeutic methods.
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Affiliation(s)
- M Zannoud
- Service d'urologie, hôpital militaire d'instruction Mohamed V, CHU Rabat, Maroc
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Kural AR, Tüfek I, Akpinar H, Gürtuğ A. Removal of urolume endoprosthesis using holmium:YAG laser. J Endourol 2001; 15:947-8. [PMID: 11769852 DOI: 10.1089/089277901753284198] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A potential complication of UroLume endoprosthesis is migration, which may necessitate removal of the stent. Stent removal may be associated with complications such as urethral injury, bleeding, and external sphincter trauma. We report a patient in whom a holmium:yttrium-aluminium-garnet (Ho:YAG) laser was used to cut the UroLume endoprosthesis into fragments, which led to easy and uneventful stent removal.
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Affiliation(s)
- A R Kural
- Department of Urology, Istanbul University, Cerrahpaşa School of Medicine, Turkey.
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30
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Affiliation(s)
- P N Schlegel
- Department of Urology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, USA
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