Assessment of the long-term results of subtrigonal phenolisation

Medical uses for phenol in the urinary tract: A possible forgotten treatment (Review)

Phenol is a chemical compound that was first used medically as an antiseptic. At low concentrations, phenol exerts local anesthetic effects achieved through denervation; at high concentrations, it exerts a potent protein-denaturing effect that induces apoptosis. Phenol injection therapy has a long history of use in urology. It is reportedly effective for hemorrhagic cystitis, benign prostate hyperplasia, overactive bladder, hydrocele, bladder tumors, interstitial cystitis and other benign urologic diseases, and it is also used as a tool to decrease bleeding during prostate surgery. The present review article summarizes the medical applications of phenol in urological field. The articles available on the medical uses of phenol are primarily older and retrospective, involving small numbers of patients. In the absence of comparative studies with other treatments, it is impossible to determine the relative benefit of phenol. However, the treatment outcomes of phenol injection are fairly well-established. Phenol therapy may be an option for patients who are poor candidates for invasive treatment. Further studies are required, however, as are improvements in the injection technique to reduce the rate of complications.

Comparison of Effectiveness of Detrusor, Suburothelial and Bladder Base Injections of Botulinum Toxin A for Idiopathic Detrusor Overactivity

PURPOSE

We compared the effectiveness of detrusor, suburothelial and bladder base injections of botulinum toxin type A in patients with idiopathic detrusor overactivity.

MATERIALS AND METHODS

A total of 45 patients with idiopathic detrusor overactivity refractory to antimuscarinic therapy were randomly allocated to receive 100 U botulinum toxin type A injected into detrusor, suburothelial and bladder base. Videourodynamic studies were performed at baseline and 3 months after treatment. Data collected included symptom score, urgency and incontinence episodes, and urgency severity score. A general satisfaction rating was also assessed as excellent, moderately improved, mildly improved or stationary. A moderately improved or excellent result was defined as successful treatment.

RESULTS

A total of 15 patients were allocated to each treatment group. A successful result at 3 months was achieved in 14 (93%) patients with detrusor, 12 (80%) with suburothelial and 10 (67%) with bladder base injection. The success rate in the detrusor, suburothelial and bladder base injection groups decreased with time to 67%, 47% and 13% by 6 months, and 20%, 20% and 6.7% at 9 months, respectively (p = 0.0253). Vesicoureteral reflux was not found in any patient after botulinum toxin type A injection. Urgency severity scores improved significantly in all groups after treatment. At 3 months after treatment significant increases in cystometric capacity and post-void residual compared to baseline were found in the detrusor and suburothelial but not in the bladder base group.

CONCLUSIONS

Intravesical injection of 100 U botulinum toxin type A by all 3 methods had a therapeutic effect on idiopathic detrusor overactivity. Bladder base botulinum toxin type A injection relieved urgency sensation but did not increase bladder capacity.

Surgical management of overactive bladder

The majority of patients with overactive bladder (OAB) can be managed with office-based techniques. When medical therapy fails as treatment for OAB, surgical intervention ranging from electric stimulation administered in the office to extensive procedures, such as augmentation or urinary diversion, may be needed. Any surgical intervention should be tailored to the patient with consideration of the degree of his or her discomfort, underlying pathology, general health, and obviously, the patient's own motivation.

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy

PURPOSE

Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence.

MATERIALS AND METHODS

Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve.

RESULTS

A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged.

CONCLUSIONS

Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.

Clam cystoplasty for the overactive bladder: a review of 23 cases

A clam enterocystoplasty was performed for refractory urge incontinence due to either idiopathic instability (13 patients) or neuropathic hyperreflexia (10 patients). Twelve patients became dry and appliance free. Of the remaining 11 wet patients, seven developed low pressure reservoirs, of whom five had stress incontinence and two had overflow incontinence. The other four patients had persistent symptomatic involuntary phasic contractions and ongoing urge incontinence. The magnitude of the surgery and the voiding dysfunction associated with the relative lack of motivation of elderly patients made the operation less successful and more hazardous in those over the age of 65. Successful outcome could be improved by careful patient selection and by performing an antistress incontinence procedure, such as implantation of an artificial urinary sphincter cuff or a cystourethropexy, where there is associated bladder outlet incompetence.

Subtrigonal phenol injection. How safe and effective is it?

A series of 24 patients underwent 27 transtrigonal phenol injections for the treatment of bladder instability. Only 2 of 18 patients with detrusor instability and 2 of 6 with detrusor hyperreflexia continued to derive benefit from the procedure 6 months after it was carried out. Serious complications attributable to phenol were seen in 2 patients in this series and in a further 4 patients referred for complications resulting from this therapy in other centres. These results and a review of the literature lead us to suggest that transvesical phenol injection should not be used except in the hyper-reflexic bladder when no alternative treatment is possible. Particular care should be exercised in patients who have undergone extensive prior surgery or radiotherapy.