Youth Top Problems in an Acute Psychiatric Sample: Describing Consumer-Nominated Treatment Needs in an Adolescent Partial Hospital Setting

Given the wide range of diagnostic presentations treated in partial hospital programs, finding efficient ways to identify and measure progress on the chief concerns of consumers in these settings is important. The current study uses a self-administered version of the Top Problems Assessment to describe treatment targets identified by youth and their caregivers presenting for care at an adolescent partial hospital setting. Caregiver-youth agreement on these chief concerns upon admission and predictors of agreement were explored. About one-third (34.65%) of caregiver-youth pairs did not match on any target problems. Although anxiety and depression were the most commonly cited top problems in this sample, caregivers and youth exhibited disagreement on these domains. Treatment teams in acute care settings such as a partial hospital program can benefit from careful assessment surrounding the initial goals of treatment as youth and their caregivers may not agree on the referral problems upon entering a program.

Assessing practical implementation of modular psychotherapy for youth in community-based settings using benchmarking

Background

Achieving high quality outcomes in a community context requires the strategic coordination of many activities in a service system, involving families, clinicians, supervisors, and administrators. In modern implementation trials, the therapy itself is guided by a treatment manual; however, structured supports for other parts of the service system may remain less well-articulated (e.g., supervision, administrative policies for planning and review, information/feedback flow, resource availability). This implementation trial investigated how a psychosocial intervention performed when those non-therapy supports were not structured by a research team, but were instead provided as part of a scalable industrial implementation, testing whether outcomes achieved would meet benchmarks from published research trials.

Method

In this single-arm observational benchmarking study, a total of 59 community clinicians were trained in the Modular Approach to Therapy for Children (MATCH) treatment program. These clinicians delivered MATCH treatment to 166 youth ages 6 to 17 naturally presenting for psychotherapy services. Clinicians received substantially fewer supports from the treatment developers or research team than in the original MATCH trials and instead relied on explicit process management tools to facilitate implementation. Prior RCTs of MATCH were used to benchmark the results of the current initiative. Client improvement was assessed using the Top Problems Assessment and Brief Problem Monitor.

Results

Analysis of client symptom change indicated that youth experienced improvement equal to or better than the experimental condition in published research trials. Similarly, caregiver-reported outcomes were generally comparable to those in published trials.

Conclusions

Although results must be interpreted cautiously, they support the feasibility of using process management tools to facilitate the successful implementation of MATCH outside the context of a formal research or funded implementation trial. Further, these results illustrate the value of benchmarking as a method to evaluation industrial implementation efforts. Plain Language Summary: Randomized effectiveness trials are inclusive of clinicians and cases that are routinely encountered in community-based settings, while continuing to rely on the research team for both clinical and administrative guidance. As a result, the field still struggles to understand what might be needed to support sustainable implementation and how interventions will perform when brought to scale in community settings without those clinical trial supports. Alternative approaches are needed to delineate and provide the clinical and operational support needed for implementation and to efficiently evaluate how evidence-based treatments perform. Benchmarking findings in the community against findings of more rigorous clinical trials is one such approach. This paper offers two main contributions to the literature. First, it provides an example of how benchmarking is used to evaluate how the Modular Approach to Therapy for Children (MATCH) treatment program performed outside the context of a research trial. Second, this study demonstrates that MATCH produced comparable symptom improvements to those seen in the original research trials and describes the implementation strategies associated with this success. In particular, although clinicians in this study had less rigorous expert clinical supervision as compared with the original trials, clinicians were provided with process management tools to support implementation. This study highlights the importance of evaluating the performance of intervention programs when brought to scale in community-based settings. This study also provides support for the use of process management tools to assist providers in effective implementation.

A longitudinal multilevel model analysis of the within-person and between-person effect of effortful engagement and academic self-efficacy on academic performance

Using data from an accelerated longitudinal study, we examined the within-person and between-person effect of effortful engagement and academic self-efficacy on academic performance across students (N=135) in elementary school. Teachers assessed participants' effortful engagement and participants rated their academic self-efficacy once per year for 3 years. Academic performance was assessed through standardized test scores in reading and math. Multilevel models indicated that within-person change in Effortful Engagement and Academic Self-Efficacy scores significantly predicted concomitant within-person change in reading test scores, B=2.71, p=.043, Pseudo-R2=.02 and B=4.72, p=.005, Pseudo-R2=.04, respectively. Participants with higher between-person levels of Effortful Engagement had higher initial reading test scores, B=10.03, p=.001, Pseudo-R2=.09, and math test scores, B=11.20, p<.001, Pseudo-R2=.15, whereas participants with higher between-person levels of Academic Self-Efficacy showed a faster rate of increase in math test scores across elementary school, B=10.21, p=.036, Pseudo-R2=.25. At the between-person level, Effortful Engagement mediated the association between Academic Self-Efficacy and both reading and math test scores, although no support was found for mediation at the within-person level. Collectively, results suggest that trait-level psychological factors can vary meaningfully within school-aged children and that both within-person change and between-person individual differences in these traits have important consequences for academic performance.

Physician Scientist Training in the United States: A Survey of the Current Literature

The declining number of physician scientists is an alarming issue. A systematic review of all existing programs described in the literature was performed, so as to highlight which programs may serve as the best models for the training of successful physician scientists. Multiple databases were searched, and 1,294 articles related to physician scientist training were identified. Preference was given to studies that looked at number of confirmed publications and/or research grants as primary outcomes. Thirteen programs were identified in nine studies. Eighty-three percent of Medical Scientist Training Program (MSTP) graduates, 77% of Clinician Investigator Training Program (CI) graduates, and only 16% of Medical Fellows Program graduates entered a career in academics. Seventy-eight percent of MSTP graduates succeeded in obtaining National Institute of Health (NIH) grants, while only 15% of Mayo Clinic National Research Service Award-T32 graduates obtained NIH grants. MSTP physician scientists who graduated in 1990 had 13.5 ± 12.5 publications, while MSTP physician scientists who graduated in 1975 had 51.2 ± 38.3 publications. Additionally, graduates from the Mayo Clinic's MD-PhD Program, the CI Program, and the NSRA Program had 18.2 ± 20.1, 26.5 ± 24.5, and 17.9 ± 26.3 publications, respectively. MSTP is a successful model for the training of physician scientists in the United States, but training at the postgraduate level also shows promising outcomes. An increase in the number of positions available for training at the postgraduate level should be considered.

Effectiveness of modular CBT for child anxiety in elementary schools

Most randomized controlled trials of cognitive-behavioral therapy (CBT) for children with anxiety disorders have evaluated treatment efficacy using recruited samples treated in research settings. Clinical trials in school settings are needed to determine if CBT can be effective when delivered in real world settings. This study evaluated a modular CBT program for childhood anxiety disorders in two elementary schools. Forty children (5-12 years old) with anxiety disorders, referred by teachers and school staff, were randomly assigned to modular CBT or a 3-month waitlist. Clinicians worked with individual families as well as teachers and school staff. Evaluators blind to treatment condition conducted structured diagnostic interviews and caregivers and children completed symptom checklists at pre- and posttreatment. The primary study outcome, the Clinical Global Impressions-Improvement scale, yielded a positive treatment response at posttreatment for 95.0% of CBT participants, as compared with only 16.7% of the waitlist participants. CBT also outperformed the waitlist on diagnostic outcomes and caregiver-report measures of anxiety. Treatment effects did not extend beyond anxiety diagnoses and symptoms. Results suggest that modular CBT delivered within the elementary school setting may be effective for the treatment of child anxiety disorders. A replication of the study results with a larger sample is indicated.

The relationship between alliance and client involvement in CBT for child anxiety disorders

Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. The sample was 31 child participants (M age = 9.58 years, SD = 2.17, range = 6-13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (Session 2) and late (Session 8) treatment phases. Two independent coding teams rated alliance and client involvement. Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.

One year follow-up to modular cognitive behavioral therapy for the treatment of pediatric anxiety disorders in an elementary school setting

The current study sought to evaluate the relative long-term efficacy of a modularized cognitive behavioral therapy (CBT) program for children with anxiety disorders. Twenty four children (5-12 years old) randomly assigned to modular CBT or a 3-month waitlist participated in a 1-year follow-up assessment. Independent evaluators blind to treatment condition conducted structured diagnostic interviews, and caregivers and children completed symptom checklists at pre- and post-, and 1 year follow-up assessments. Analyses revealed that 71.4% of children who received CBT demonstrated a positive treatment response 1 year following treatment, and 83.3% were free of any anxiety diagnosis at 1 year follow-up. Analyses further revealed robust effects of intervention on diagnostic outcomes, caregiver- and child-report measures of anxiety at 1 year follow-up. Results provide evidence of an ongoing advantage on anxiety-specific outcomes for this modularized school-based CBT program 1 year post-treatment.

Child-therapist alliance and clinical outcomes in cognitive behavioral therapy for child anxiety disorders

BACKGROUND

Few studies have examined the link between child-therapist alliance and outcome in manual-guided cognitive behavioral therapy (CBT) for children diagnosed with anxiety disorders. This study sought to clarify the nature and strength of this relation.

METHODS

The Therapy Process Observational Coding System for Child Psychotherapy - Alliance scale (TPOCS-A; McLeod, 2005) was used to assess the quality of the child-therapist alliance. Coders independently rated 123 CBT therapy sessions conducted with 34 children (aged 6-13 years) diagnosed with anxiety disorders. Parents reported on children's symptomatology at pre- mid-, and post-treatment.

RESULTS

A stronger child-therapist alliance early in treatment predicted greater improvement in parent-reported outcomes at mid-treatment but not post-treatment. However, improvement in the child-therapist alliance over the course of treatment predicted better post-treatment outcomes.

CONCLUSIONS

The quality of the child-therapist alliance assessed early in treatment may be differentially associated with symptom reduction at mid- and post-treatment. Results underscore the importance of assessing the relation between alliance and outcome over the course of therapy to clarify the role the child-therapist alliance plays in child psychotherapy.

Thalamic involvement and its impact on clinical disability in patients with multiple sclerosis: a diffusion tensor imaging study at 3T

BACKGROUND AND PURPOSE

Several studies suggest that grey matter involvement may play a role in multiple sclerosis (MS) pathology. Diffusion tensor imaging (DTI) at 3T was used to investigate the presence of damage to the normal-appearing thalamus in MS and its relationship with disability.

MATERIALS AND METHODS

Twenty-four patients with relapsing-remitting (RR, n = 13, age = 41.7 +/- 6.1, Expanded Disability Status Scale [EDSS] score = 2.2 +/- 1.2) and secondary-progressive (n = 11, age = 46.9 +/- 9.6, EDSS = 5.9 +/- 1.0) MS and 24 age- and sex-matched healthy volunteers were studied. Fractional anisotropy (FA) and mean diffusivity (MD) were measured in regions of interest of normal-appearing thalamus. We examined group differences in MD and FA and correlations between DTI-derived metrics and clinical or imaging measures of disease.

RESULTS

Patients with MS had higher thalamic FA (P < .0001) and MD (P = .035) than volunteers. MD values correlated with the Paced Auditory Serial Addition Task (r = -0.43, P = .034) and motor EDSS (r = 0.47, P = .021) scores. In patients with RRMS, MD values correlated with global EDSS (r = 0.75, P = .003) and motor EDSS (r = 0.68, P = .010). Correlations were found between MD values and T1 and T2 lesion load (r = 0.58, P < .05) and brain parenchymal fraction (r = -0.46, P < .05).

CONCLUSIONS

DTI was able to detect abnormalities in normal-appearing thalamus of patients with MS. The strength of association between thalamic DTI measures and functional impairment was in the same range as those seen with standard MR imaging disease measures. The assessment of the integrity of the thalamus with DTI is a promising metric as a marker of disease for future studies.

A case study on the effect of neutralizing antibodies to interferon beta 1b in multiple sclerosis patients followed for 3 years with monthly imaging

Interferon beta (IFN-beta) is among the first-line treatment options for patients with multiple sclerosis (MS). A potential caveat of therapy, however, is the development of neutralizing antibodies (NAb) and/or neutralizing activity (NA) non-antibody mediated, although debate is still ongoing as to whether NAb significantly hampers the efficacy of the drug or rather represents an immunologically irrelevant epiphenomenon. In the present study, we describe the effect of NAb on IFN-beta-1b through clinical and magnetic resonance imaging (MRI) outcome measures of five relapsing-remitting multiple sclerosis (RRMS) patients who were treated with 250 mug of subcutaneously administered IFN-beta-1b every other day and developed NAb at varying titres and times during the course of therapy. Despite the small number of NAb(+) patients, heterogeneity in MRI/clinical response to IFN-beta-1b was identified. Response to IFN-beta-1b therapy was observed in the absence or presence of NAb. Also observed was failure to IFN-beta-1b coincident with high and sustained NAb titres, but also before NAb development or in the presence of low NAb titres. Multiple MRI and NAb measurements performed within the same individual allow for a better description of the complex heterogeneous response to IFN-beta-1b with respect to NAb occurrence.

Patients' competence in and performance of cognitive therapy skills: Relation to the reduction of relapse risk following treatment for depression

Cognitive therapy (CT) for depression is designed to teach patients material that is believed to help prevent relapse following successful treatment. This study of 35 moderately to severely depressed patients who responded to CT provides the 1st evidence to suggest that both development and independent use of these competencies predict reduced risk for relapse. Among patients who responded to treatment, both CT coping skills and in-session evidence of the independent implementation of CT material predicted lower risk for relapse in the year following treatment. These relationships were not accounted for by either symptom severity at the end of treatment or symptom change from pre- to posttreatment. Self-esteem, assessed at posttreatment, failed to predict risk for relapse in the year following treatment. Thus, CT coping skills and independent use of CT principles, but not overall satisfaction with oneself, appear to play an important role in relapse prevention.

Laparoscopic bilateral nephroureterectomy and bladder cuff excision for native renal pelvic and ureteral transitional cell carcinoma after renal transplantation

A 37-years-old female who was suffering from end-stage renal disease for about 6 years received allograft renal transplantation 4 years ago. She has been receiving 50mg of Cyclosporin A orally daily for immuno-suppression since then. Gross haematuria was noted and computerised tomography showed native left renal pelvic and ureteral multi-focal transitional cell carcinoma with severe hydronephrosis. Laparoscopic bilateral nephroureterectomy and bladder cuff excision were performed. In the past, history of previous operation was considered a relative contraindication for laparoscopic surgery. To our knowledge, we present the first case of laparoscopic treatment for native renal pelvic and ureteral transitional cell carcinoma after renal allograft transplantation without a hand-assisted device. This case shows the feasibility of laparoscopic bilateral nephroureterectomy in patients with transplanted kidneys.

Assessment of a three-dimensional operating system with skill tests in a pelvic trainer

OBJECTIVES

To compare the performance of laparoscopic skill assisted by a traditional two-dimensional (2D) and a three-dimensional (3D) endoscopic video system in a pelvic trainer.

MATERIALS AND METHODS

The 3D imaging system (DeepVision((R)), Automated Medical Products Corp.) consists of a traditional single lens optic laparoscope, a light source, an endoscopic camera (Stryker), a DeepVision processor and a DeepVision monitor. The 2D images could be obtained with the same system without turning on the DeepVision processor. Thirty-four medical personnel with no laparoscopic surgical experience were enrolled to perform two skill tests, the object-pick-up and spatial orientation test in a trainer box. They were randomly divided into two groups, one group performed the test under 2D conditions first and 3D later, and another group performed the test under 3D conditions first and 2D later. The duration needed to complete the skill tests was recorded and the differences on performance time under 2D and 3D conditions were calculated for each participant. Two-way ANOVA was used to analyze the statistic difference on the performance time in two conditions.

RESULTS

The duration needed to complete the initial skill tests was similar among 2D and 3D conditions. For both tests, the average performance time decreased significantly for the second attempt regardless of 2D or 3D conditions. Statistic analysis disclosed significant difference for learning factor (p < 0.001 for object-pick-up test and p < 0.01 for spatial orientation test), but no significant difference between 2D and 3D conditions (p = 0.276 for object-pick-up test and p = 0.327 for spatial orientation test).

CONCLUSION

A significant decrease of the performance time at the second attempt reflected the importance of a learning process in laparoscopic surgery. It appears that no significant benefits were obtained by this 3D operating system for surgeons without laparoscopic surgical experience.

Life-threatening germ cell tumor arising in cryptorchidism: a case report

We report a case of life-threatening germ cell tumor in abdominal cryptorchidism. A 32-year-old man presented with a three-month history of dyspnea, loss of appetite, general weakness and a large abdominal mass. Physical examination revealed vacancy of the right scrotal contents. Chest radiograph showed massive left pleural effusion. Abdominal ultrasound revealed ascites, right hydronephrosis and the presence of an 18 x 15-cm heterogeneous echogenic mass in the upper abdomen and right iliac fossa. Abdominal computerized tomography (CT) revealed the presence of a large heterogeneous tumor and an enlarged (4 x 4-cm) retroperitoneal lymph node. Sonoguided needle biopsy of the abdominal mass demonstrated malignant cells of an uncertain type and origin. Serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) concentrations were elevated. Under the diagnosis of metastatic nonseminomatous germ cell tumor in abdominal cryptorchidism, the patient received three cycles of cisplatin-based combination chemotherapy followed by resection of the abdominal residual cryptorchid tumor. Histologically, the tumor showed marked necrosis without viable cancer. The patient had remained free of disease for seven months following surgery.

Clinical experiences of germ cell tumor in cryptorchid testis

The increased risk of malignancy occurring in the cryptorchid testis is well established. In order to investigate the management and outcome of germ cell tumor in cryptorchid testis, we retrospectively reviewed the records of 11 patients with cryptorchid tumor treated at our hospital between January 1973 and December 1996. Mean patient age at diagnosis was 47.6 years (range, 22-80). Of these patients, 3 were found in the inguinal area and 8 in the abdomen. Six occurred in the right cryptorchid testis and 5 in the left. Four patients presented with stage I disease, 4 with stage II, and 3 with stage III. Median follow-up period was 48.0 months (range 1-163). All 3 inguinal cryptorchid tumors and 6 of 8 abdominal cryptorchid tumors were seminoma. The remaining 2 abdominal cryptorchid tumors were nonseminomatous germ cell tumor. Of the 3 patients with inguinal cryptorchid seminomas, 2 with stage I disease were treated with prophylactic radiotherapy to nodal areas and 1 with stage III disease was treated with chemotherapy. Eight patients with abdominal cryptorchid tumors were treated with multidisciplinary approaches, including radiotherapy, cisplatin-based combination chemotherapy, and surgery. The overall survival rate for patients with inguinal and abdominal cryptorchid tumor was 81.8%. Two patients with stage III disease died during treatment and the remaining 9 patients are still alive without evidence of disease.

Complicated urinary tract infection: analysis of 179 patients

BACKGROUND

The aim of our study was to investigate the incidence, bacteriology, management and outcome of complicated urinary tract infections (UTIs) at the Veterans General Hospital-Taipei.

METHODS

Between June, 1993, and July, 1994, medical records of 2,566 patients admitted to the Division of Urology, Veterans General Hospital-Taipei, were retrospectively reviewed. Of these patient, 1,322 had a diagnosis of benign prostatic hyperplasia (BPH), 607 were admitted for renal stones, 496 for ureteral stones, 75 for transitional cell carcinoma (TCC) of the urinary bladder, 47 for renal tumors and 19 for TCC of the ureter. Among all patients studied, 179 (6.98%) acquired a complicated UTI. Of these, 81 were admitted for BPH, 46 for renal stones, 42 for ureteral stones, five for TCC of the urinary bladder, three for renal tumors and two for TCC of the ureter.

RESULTS

Of the 179 patients with complicated UTIs, 155 were men and 24 were women. The urine culture positive rate was 76.0% (136/179) and the most common bacteria were Escherichia coli, Proteus mirabilis and Pseudomonas aeruginosa. The principle mode of treatment included parenteral antibiotics and urinary diversion (percutaneous nephrostomy and Foley catheterization), when necessary. The infection control rate for these complicated UTIs was 96.3% for BPH, 95.5% for renal stone, 97.6% for ureteral stone, 80% for TCC of the urinary bladder, 100% for renal tumor and 100% for TCC of the ureter. Mortality due to complicated UTI was 3.9% (7/179).

CONCLUSIONS

We concluded that the prognosis of complicated UTI is good if diagnosis and appropriate treatment are given promptly. Early drainage to relieve obstruction and intravenous antibiotics are initially necessary. Surgical intervention is required to resolve functional or structural abnormalities after the UTI has been controlled.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective

OBJECTIVES

To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy.

METHODS

A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed.

RESULTS

Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51.

CONCLUSIONS

Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Is renal function at the tumor side a prognostic factor in ureteral transitional cell carcinoma?

OBJECTIVES

To evaluate whether the ipsilateral renal function on the tumor side is a prognostic factor in transitional cell carcinoma (TCC) of the ureter.

PATIENTS AND METHODS

We retrospectively reviewed 129 consecutive patients with ureteral TCC between September 1973 and July 1993 at our hospital. There were 98 males and 31 females aged from 31 to 84 years (mean 64.9). Of them, 126 patients who received intravenous pyelography (IVP) were divided into 3 groups according to their radiological findings (group 1: nonvisualization of kidney at tumor side; group 2: hydronephrosis or hydroureter; group 3: no obstruction). Eighty patients receiving radionuclide (131I-hippuran) renal function test (RRFT) with available effective renal plasma flow (ERPF) were divided into 2 groups using ipsilateral ERPF 50 ml/min as a cutoff value (group 1: < 50 ml/min; group 2: > or = 50 ml/min). The mean survival of each group was estimated by the Kaplan-Meier method.

RESULTS

For patients receiving IVP, the mean survivals were 61.7, 99.7 and 83.8 months for groups 1, 2, and 3, respectively, and the differences between each 2 of the 3 groups were statistically significant (p < 0.05). For patients having RRFT, the mean survivals were 65.8 months for group 1 and 89.2 months for group 2 patients, and the difference between them was statistically significant (p < 0.05). When renal function, tumor number, grade, stage and type of treatment were analyzed using a multivariate method, only tumor stage was statistically significant as a prognostic factor.

CONCLUSION

Ipsilateral renal function at the tumor side is not a good prognostic factor for patients with ureteral TCC. However, when the stage of tumor is not available, renal function at the tumor side may provide an implication of the patient's prognosis.

A PC-based surgical simulator for laparoscopic surgery

Surgical simulators for minimally invasive surgery have been developing in the 1990s. Most of them use high-end UNIX workstations for real-time simulation of complex human organ models. Only few of them have input devices with force feedback. Recently, personal computer technologies have made real-time display of relatively complex models feasible. We are developing an Intel-based laparoscopic surgical simulator that provides near real-time intuitive interaction between the trainee and simulated models of human organs. The surgical simulator has a prototypical scenario of cholecystectomic surgery. It can interactively simulate the deformation and cutting of cystic duct and vein. In addition, a set of input devices with force feedback has been designed and tested to imitate the manipulation of surgical instruments. The input device has five degrees of freedom and three of them are driven by DC motors to produce force feedback.

Clinical outcome at 3 months after transurethral vaporization of prostate for benign prostatic hyperplasia

OBJECTIVES

To evaluate the clinical outcome of transurethral vaporization of the prostate (TUVP) for the management of benign prostatic hyperplasia (BPH).

METHODS

Between March and June 1995, 30 patients with symptomatic BPH treated by TUVP were enrolled in this study. Transrectal ultrasonography (TRUS) was done preoperatively. American Urological Association (AUA) symptom score determination, pressure flow study, and questionnaire (for evaluating potency) were done preoperatively and 3 months postoperatively.

RESULTS

The average age was 70.5 years (range 60 to 83) and estimated prostate size by TRUS before surgery was 33.8 +/- 14.0 g. The average AUA symptom score decreased significantly 3 months after TUVP (6.2 +/- 7.8 versus 18.2 +/- 9.0; P < 0.01). The maximum urine flow rate (Qmax) was 11.1 +/- 3.7 mL/min before TUVP (mean +/- SD) and 17.0 +/- 6.5 mL/min 3 months after TUVP, whereas the detrusor pressure at maximum urine flow (Pdes at Qmax) was 61.0 +/- 23.9 and 41.2 +/- 15.2 cm H2O, respectively. Qmax increased and Pdes at Qmax decreased significantly 3 months after TUVP. Of the 30 patients, 3 (10%) developed bladder neck contracture. Of the 24 patients who were potent sexually before operation, 3 (12.5%) developed impotence 3 months after surgery.

CONCLUSIONS

TUVP is an effective alternative surgical procedure to relieve obstruction for patients with symptomatic BPH. However, cautious attitude on its usage is advocated based on our preliminary results indicating the occurrence of late complication such as impotence and bladder neck contracture.

Alterations in pulmonary function after retroperitoneoscopic surgery

OBJECTIVE

To evaluate and compare changes in pulmonary function after retroperitoneoscopic and open surgery.

PATIENTS AND METHODS

From June 1994 to October 1995. 11 patients (five men and six women, mean age 44.7 years, range 29-69) underwent retroperitoneoscopic procedures (Group 1) and 11 patients (eight men and three women, mean age 57.5 years, range 22-73) underwent flank-incision procedures (Group 2). The surgery comprised eight adrenalectomies and one each of nephroureterectomy, nephrectomy and pyelolithotomy in Group 1, and five adrenalectomies, four nephroureterectomies, one ureterolithotomy and one excision of a retroperitoneal tumour in Group 2. Pulmonary function tests (PFTs) were performed before and 3 days after surgery; the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), forced expiratory volume at 25% (FEV25%), FEV1/FVC, vital capacity (VC), total lung capacity (TLC), residual lung volume (RV) and functional residual capacity (FRC) were compared between the groups. The post-operative changes in the PFTs were assessed using a paired t-test and the degree of change in both groups compared using the Mann-Whitney U-test. Other factors possibly influencing PFT were analysed using multiple regression.

RESULTS

Pulmonary function was impaired in both groups on the third day after surgery. In Group 2, the FVC, FEV1, FEV25%, VC and TLC had declined significantly (all P < 0.05) from the pre-operative value. In Group 1, only the FVC and VC decreased significantly (P < 0.05). Post-operative pulmonary complications occurred in two patients in Group 2 but in none of those in Group 1, showing that pulmonary function was generally less affected in Group 1 than in Group 2.

CONCLUSION

Although pulmonary function was impaired 3 days after surgery in both groups, retroperitoneoscopic surgery, by eliminating a large flank incision, caused less post-operative pulmonary dysfunction than open surgery.

Changes in urinary output and electrolytes during gaseous and gasless laparoscopy

Urological laparoscopy has gained increasing acceptance recently. Alterations in renal water and electrolyte homeostasis by carbon dioxide peritoneal insufflation, retroperitoneal insufflation and abdominal wall lifting were measured in 30 well-hydrated pigs over a 2-h period. Oliguria was observed after gaseous insufflation but not alter lifting the abdominal wall. Return to normal urinary output was observed at 30 min after release of pneumoretroperitoneum, and 60 min after pneumoperitoneum. Creatinine clearance declined, while the clearance rates of potassium, sodium and urea remained unchanged during peritoneal and retroperitoneal insufflation. An elevated serum aldosterone concentration was found which may mediate the increased urinary excretion of potassium and decreased urinary excretion of sodium found during peritoneal insufflation. Renal function remained stable, despite an elevation of serum creatine kinase being elicited after lifting the abdominal wall. In conclusion, significant changes in water and electrolyte homeostasis occurred gaseous, not gasless, laparoscopy in pigs.

Malakoplakia of the prostate forming a fistulous tract to rectum: a case report

Malakoplakia is a rare lesion of granulomatous inflammation which mainly affects urinary bladder but may involve other parts of the body. Differentiation from neoplastic process is often difficult due to its tumorous gross appearance and similarity to carcinoma microscopically. Malakoplakia of the prostate is even rare. We present a case of prostatic malakoplakia masquerading as a rectal tumor due to formation of a fistulous tract to the rectal muscular layers accompanied with ulceration of the rectal mucosa. Its clinical course is different from those of most reported cases, while the outcome is as satisfactory as in usual cases.

A porcine model for renal hemodynamic study during laparoscopy

Laser Doppler flowmetry (LDF) is a sensitive method for the measurement of microvascular blood flow in tissue. The method has been found useful for estimating skin, liver, or gastrointestinal blood flow. Whether it can be applied laparoscopically and whether it is able to measure the intraparenchymal blood flow of an intraabdominal organ is still unknown. In a pilot study, 6 pigs received a laparotomy for placement of a 19-gauge LDF needle probe into the renal parenchyma. Three different locations of the lower pole kidney were chosen for the blood flow measurement. The reliability of using the instrument to measure the renal tissue blood flow was assessed by comparison of the results of renal arterial blood flow obtained from a well-established methodology--ultrasonic Doppler flowmetry. Recordings were taken following (a) intravenous administration of 0.005 mg/kg norepinephrine, (b) manual compression of the suprarenal aorta, and (c) intravenous injection of a lethal dose of phenobarbital (50 mg/kg). Measurements of LDF were possible in all kidney units. The renal tissue perfusion detected by LDF correlated excellently with the renal arterial blood flow under different renal perfusion pressures. The feasibility of using LDF probe to measure the renal tissue perfusion in a laparoscopic model was then assessed in 15 pigs. Under pneumoperitoneum, the right kidneys were approached transperitoneally with the animal in the decubitus position. A total of three trocars were used. The peritoneum and Gerota's fascia were incised and the LDF needle probe was manipulated and inserted by an endoforceps into the renal tissue via a 5-mm trocar. The insertion of the LDF needle probe was technically feasible in all 15 kidney units, and the depth of insertion could be adjusted under direct vision. Baseline values for the renal cortical and renal medullary blood flow were 50.1 +/- 17.7 and 8.8 +/- 3.3 ml/min/100 g tissue, respectively. Spatial variations of the LDF measurements averaged 6%, and temporal variations over 15 min averaged 5%. Four additional hemodynamic parameters were simultaneously recorded, including left carotid artery blood flow, aortic blood pressure, inferior vena caval pressure, and intraabdominal pressure. It appears that systemic and renal hemodynamic parameters can be monitored reliably and continuously in the porcine model. This method allows further information concerning hemodynamic changes and safety of laparoscopy to be obtained.

Laparoscopic ligation of bilateral spermatic varices under epidural anesthesia

Feasibility and safety of laparoscopic ligation of bilateral internal spermatic varices under epidural anesthesia were assessed in 11 patients. Another 11 patients undergoing the same procedure under ventilation-assisted anesthesia served as controls. Patients in both groups belonged to the American Society of Anesthesia functional class I. Arterial blood analyses were obtained (1) in the horizontal supine position; (2) in the 15 degrees Trendelenburg position; (3) at 15 min after carbon dioxide pneumoperitoneum insufflation, and (4) at 15 min after desufflation in the supine position. In the epidural anesthesia group arterial blood parameters and respiratory rate remained stable in the Trendelenburg position. After intraperitoneal insufflation of carbon dioxide for 15 min, the arterial carbon dioxide level increased from 40.1 +/- 2.2 to 42.1 +/- 2.6 mm Hg, the respiratory rate increased from 17.0 +/- 1.4 to 20.6 +/- 1.2/min, the blood pH value decreased from 7.386 +/- 0.027 to 7.355 +/- 0.034, all values showing statistically significant differences. These changes returned to the preinsufflation level 15 min after release of the pneumoperitoneum. The above-mentioned parameters remained unchanged under the pneumoperitoneum by assisted ventilation in the control group. The mean time of surgery was similar in both groups: 82 and 90 min for the groups having general and epidural anesthesia, respectively. All laparoscopic procedures were accomplished successfully under general anesthesia. However, failure to ligate the internal spermatic varices occurred in 3 patients under epidural anesthesia, mainly due to patient intolerance to abdominal distension. The operation was continued under intubated general anesthesia for relaxing the abdominal muscle to provide an adequate working space. In 8 patients being successfully operated under epidural anesthesia, 5 experienced mild but tolerable abdominal distension; 2 complained of shoulder pain intraoperatively. Although laparoscopic ligation of internal spermatic varices could be accomplished in some patients under epidural anesthesia, it carried a high failure rate, more intraoperative morbidity, and significant arterial blood gas alterations. Routine ventilation-assisted anesthesia is suggested for therapeutic laparoscopy even for an easy procedure such as the ligation of the internal spermatic varices.

The impact of pneumoperitoneum, pneumoretroperitoneum, and gasless laparoscopy on the systemic and renal hemodynamics

BACKGROUND

The use of therapeutic laparoscopy has become widespread recently. It is important to assess the effects of gaseous and gasless laparoscopy on systemic and renal hemodynamics.

STUDY DESIGN

A prospective controlled animal study was performed on 40 well-hydrated pigs. Systemic and renal hemodynamics were monitored during peritoneal insufflation, retroperitoneal insufflation, and abdominal wall lifting for a period of two hours. A laser Doppler flow meter was applied laparoscopically to measure the renal cortical tissue perfusion.

RESULTS

Peritoneal insufflation of carbon dioxide to a pressure of 15 mm Hg elicited transient elevations of the aortic pressure and carotid arterial blood flow. Unilateral pneumoretroperitoneum caused a smaller change on systemic hemodynamics. Pneumoperitoneum and pneumoretroperitoneum caused oliguria. Superficial renal cortical blood flow reduction decreased by an average of 60 percent in the compressed kidney, and blood flow returned to the pre-insufflation level after the pressure was released. A gradual decrease of tissue perfusion in the contralateral kidney and a concomitant gradual increase of the intra-abdominal pressure were observed when pneumo-retroperitoneum was maintained for two hours. No significant changes in urinary output and in systemic and renal hemodynamics were found when the abdominal wall was lifted up with a force equivalent to 15 mm Hg.

CONCLUSIONS

Significant systemic and renal hemodynamic changes were elicited in gaseous but not in gasless laparoscopy, which may explain the decreased urinary output observed during gaseous laparoscopy. Pneumoperitoneum caused greater systemic and renal hemodynamic alterations than pneumoretroperitoneum; however, the effects were transient and reversible after a period of two hours.

Direct needle insufflation for pneumoretroperitoneum: anatomic confirmation and clinical experience

OBJECTIVES

The feasibility and safety of direct needle insufflation to create pneumoretroperitoneum was assessed by an imaging study and clinical experience.

METHODS

A total of 10 patients without previous retroperitoneal surgery or diseases received computed tomography scans of the retroperitoneum 2 cm above the iliac crest. Distances between quadratus lumborum and colon (Q-C distance) were measured in the supine and lateral positions. Changes of Q-C distance were calculated when the patient was changed from the supine to the lateral position. Operative charts on 38 retroperitoneoscopic procedures were collected prospectively to assess complications related to direct needle insufflation, which was performed by inserting a 14 G Veress needle blindly along the posterior axillary line 2 cm above the iliac crest.

RESULTS

Q-C distance increased from 8.7 to 27.3 mm (left side) and 4.6 to 18.1 mm (right side) when the patient was changed from the supine to the lateral position, both P values < 0.05. An average distance of 23 mm between colon and quadratus lumborum was found when patients were lying laterally. The misplacement of a Veress needle was encountered in 1 patient, in which a prefascia insufflation resulted in conversion of the endoscopic procedure. Needle puncture caused no visceral or great vessel injury.

CONCLUSIONS

Significant anterior movement of the colon was found when patients were changed from the supine to the lateral position. It provided a window for inserting the Veress needle blindly into the retroperitoneum. The high success rate (97%) and low complication rate of direct needle insufflation were found in actual clinical applications. We considered needle insufflation a safe and effective method of establishing a pneumoretroperitoneum for any retroperitoneoscopic procedure.

Laparoscopic nephrolysis for chyluria: case report of long-term success

Laparoscopic nephrolysis was performed in an 81-year-old man with recurrent chyluria. A total of five trocars were used for approaching the lymphatic ducts over the right ureter and renal hilum. The lymphatic ducts identified were easily ligated under laparoscopic magnification. The recovery of this patient was quick and uneventful. The follow-up urinalysis for chyle was negative, and his serum albumin concentration increased from 3.0 g/dL to 4.2 g/dL at 2 years postoperatively. This case report attests to the long-term efficacy of a laparoscopic approach to ligation of lymphatic fistulas for the treatment of recalcitrant chyluria.

Retroperitoneal laparoscopic nephrectomy utilizing three-dimensional camera. Case report

A retroperitoneal laparoscopic nephrectomy was performed utilizing a novel three-dimensional laparoscope. This case report illustrates the potential benefits of this new technology for complex laparoscopic procedures.

Effects of intra-abdominal pressure on renal tissue perfusion during laparoscopy

An animal model was established to study the effects of elevated intra-abdominal pressure (IAP) on systemic and renal hemodynamics during laparoscopy. In a pilot study in five dogs, we simultaneously recorded carotid artery blood flow (CABF), carotid artery blood pressure (CABP), inferior vena caval pressure (IVCP), renal parenchymal blood flow, and IAP. The renal parenchymal blood flow was measured by a laser Doppler flowmetry (LDF) needle probe and the renal artery blood flow by an ultrasonic Doppler probe, both placed through laparotomy. The reliability and reproducibility of these two measurements at different renal perfusion pressures were documented. The established method was then used to assess the effects of increased IAP on renal hemodynamics during laparoscopy in six pigs. Pneumoperitoneum was achieved by insufflating the abdominal cavity with air. The LDF needle probe was inserted into the renal parenchyma laparoscopically. An increase in IAP from 0 to 40 mm Hg did not influence CABP. However, significant decreases in CABF were seen from 190.8 +/- 59.5 mL/min at 0 mm Hg IAP to 169 +/- 43.6 mL/min at 15 mm Hg. The CABF decreased in a linear fashion as IAP was increasing (correlation coefficient R = 0.976). Renal cortical blood flow (RCBF) decreased from 50.1 +/- 17.7 mL/min per 100 g at 0 mm Hg to IAP to 21.2 +/- 9.6 mL/min per 100 g of tissue at 15 mm Hg. There was an exponential correlation between IAP and RCBF (R = 0.897).(ABSTRACT TRUNCATED AT 250 WORDS)

Deoxyribonucleic acid histogram of testes in primary transsexualism

The influence of oestrogen on spermatogenesis was evaluated by comparing its effect on the testes of primary male transsexuals and those who had undergone hormone therapy for prostatic carcinoma. Eight primary transsexuals were studied. They had been diagnosed on clinical and psychiatric evidence and had been on oestrogen therapy for several years since puberty. Histological sections of testicular tissue obtained at reassignment surgery from 8 phenotypic male transsexuals (aged 24-32 years) with an XY chromosome complement were studied by light microscopy. The formalin-embedded specimens were analysed by flow cytometry for deoxyribonucleic acid (DNA) histograms. Both the histology and DNA histograms revealed a pattern of maturation arrest in 12 of 16 testes in which the diploid cell compartment occupied most of the spermatogenetic element, followed by tetraploid and monoploid cells. Two testes showed impaired spermatogenesis and 2 were normal. The DNA histograms and pathology were also evaluated in 20 testes after 3 to 8 years of hormone therapy in patients with advanced prostatic carcinoma (aged 60-78 years). No maturation arrest was found in these patients. Sixteen of them had a pattern of fibrosis and atrophy and 4 had impaired spermatogenesis. It was concluded that oestrogen influenced spermatogenesis and affected the maturation of spermatogonia mostly during puberty.

Flow cytometric study of anterior chamber aqueous humor after neodymium: yttrium aluminum garnet laser iridotomy

Laser iridotomy is a safe and effective treatment of pupillary-block glaucoma; however, increased intraocular pressure (IOP) may occur after the procedure. A flow cytometric study of aqueous humor was done 1.5 hours after neodymium: yttrium aluminum garnet laser iridotomy in 20 eyes. This sensitive and precise method did not reveal an apparent correlation between the degree of postoperative IOP spike and the amount of inflammatory cells or cellular debris induced by laser iridotomy. Although slit-lamp examination showed many "cells" in the anterior chamber in most after laser iridotomy, DNA histography found only scanty chromatin coating cells. We believe the so-called cells observed using slit-lamp biomicroscopy might not all be real cellular aggregates but rather aggregates of protein or fibrin in some situations.

Laparoscopic ligation of internal spermatic vein

Laparoscopic procedures have long been a standard form of treatment for gynaecological disorders but have only recently shown promise in the evaluation and treatment of urogenital diseases, such as pelvic lymphadenectomy. We performed laparoscopic ligation of the bilateral internal spermatic veins in 15 male pigs. The average operative time was 20 min and operative morbidity was minimal, comprising mild subcutaneous emphysema around the trocars. Engorgement of the spermatic vein proximal to the endoclip site was noted. There was no operative mortality. Laparoscopic ligation of the internal spermatic veins seems to be a feasible method for the treatment of varicoceles, especially bilateral lesions.

[Laparoscopic orchiectomy for intraabdominal cryptorchism and varicocelectomy]

Laparoscopic procedures have recently been used in the evaluation and treatment of some urogenital diseases. A case of right intraabdominal cryptorchism associated with left varicocele was successfully treated by laparoscopic orchiectomy and ligation of the contralateral internal spermatic vein concomitantly. This new technology can be easily performed and has the advantages of less tissue trauma, easy application for bilateral lesions, and less patient morbidity. We consider laparoscopy is a promising method for the diagnosis and treatment of intraabdominal testis.

Laparoscopic nephrectomy in a porcine model

Laparoscopic nephrectomy was performed in 15 male pigs, the procedure was successful in 14. Extraction of the intact kidney through a 5-cm lower abdomen incision was done in 7 animals; complete destruction and evacuation of the kidney was accomplished by a round-knife suction device through a 1-cm port in another 7 pigs. Grossly, the specimen consisted of sausage-like tubular renal tissue and a small amount of tissue debris. Pathology revealed that the glomerular and tubular structures were well preserved, no interstitial hematoma could be found. Four ports were usually used, one 1-cm umbilical camera port, one 0.5-cm port for ureter traction, and two 1-cm working ports along the midclavicular line. All the pigs recovered uneventfully. The average operation time was 3 h 20 min. The application of endo-GIA (United States Surgical Corporation) for renal hilum reduced the operative time to 2 h 20 min. Complications included renal vein tear during endoclip application and cutting in the first case, mild subcutaneous emphysema in 2 cases. This first pig received exploratory laparotomy for the repair and ligation of the renal vein. No more major complications occurred with increasing experience. From this porcine experiment, we conclude that the combination of laparoscopy, a tissue destroyer and an endobag for the entrapment of kidney seem to be a promising technique for clinical nephrectomy.

Comparison between histopathology and DNA histogram of testis

From January to July 1989, the DNA histogram of testicular open biopsies was done for 11 patients of primary infertility and 7 patients of a control group. There were 2 failures in these 36 specimens. The flow cytometric analysis revealed characteristic patterns in the relative numbers of haploid (1C), diploid (2C), and tetraploid (4C) cells. In the presence of normal spermatogenesis, the haploid compartment contained the majority of cells, followed by the diploid, and then the tetraploid (1C greater than 2C greater than 4C). The other diagnostic criteria of flow cytometry were as follows: hypospermatogenesis (2C greater than 1C greater than 4C), the maturation arrest (2C greater than 4C greater than 1C), and Sertoli-cell-only syndrome (2C, near 100%). According to the aforementioned diagnostic criteria, the results of DNA histograms were compared with the histopathology diagnosed by junior or senior pathologists. These patterns of DNA histograms correlated with the diagnoses by senior pathologists in 28 of 34 specimens (82.6%), while there were only 20 of 36 pathologic diagnoses (55.6%) which matched between junior and senior pathologists. It is shown that abundant experience is needed for testis pathologists to diagnose accurately. The DNA histograms correlate well with pathological findings, with the advantages of quantification and fewer specimens needed. In conclusion, testicular tubular cell DNA histograms appear to be a reliable modality in the evaluation of spermatogenesis. They provide the quantitative information of sperm maturation and help in making appropriate decisions in the management of male infertility.

Stone incrustation: a relevant complication of the intraprostatic spiral

Six high operative risk patients with urinary retention caused by benign prostatic hyperplasia were managed with an intraprostatic spiral at our hospital. Three of them had severe coronary artery disease, 1 had uremia, 1 had cerebral stroke and 1 had poorly controlled diabetes mellitus. The urinary retention was successfully relieved by the intraprostatic spiral in all patients. No operative mortality or severe complication was encountered. One patient experienced a repeat attack of urinary retention due to proximal migration of the spiral. Four patients complained of urgency, which was relieved by anticholinergic agents. Stone incrustation was found on 2 out of 3 spirals removed (66%), and the stone turned out to be calcium phosphate and struvite by scanning electron microscopy and infrared spectrophotometry. In 1 patient, stone formation was so abundant that it almost obstructed the lumen of the redundant tip of the spiral. From our preliminary results, the intraprostatic spiral seems to be a good alternative to an indwelling catheter for patients awaiting prostatectomy. Nevertheless, the potential complication of stone incrustation should be anticipated and it is suggested to remove the device as soon as possible or to replace it at regular intervals.

Penile brachial index in impotent patients with coronary artery disease

From March to July 1989, a total of 40 patients, who had received coronary catheterization, answered questionnaires concerning sexual potency. In those 30 patients with a diseased coronary artery, only 2 (6.6%) had no erectile dysfunction subjectively. On the contrary, 4 of 10 (40%) patients with angiographically proven normal coronary artery complained of erectile dysfunction. Penile Doppler ultrasonography was performed in 30 patients. The mean penile brachial index (PBI) of 8 patients with a normal coronary artery was 0.82 +/- 0.1, as compared with the diseased group, 0.73 +/- 0.1 (p = 0.05). When these patients were further divided into two groups by a PBI of greater or less than 0.65, there was also no significant difference in the degree of obstruction of the three main coronary arteries between these two groups. There was no correlation between PBI and obstruction of the left anterior descending artery (r = 0.316, p = 0.689). Most of the patients (93.4%) with an abnormal coronary artery had erectile dysfunction. Nevertheless a poor correlation was noted between the PBI and the severity of coronary artery obstruction. Our study suggests that it is hard to use PBI alone as a predictor of future major thromboembolic heart attack.

Prophylactic bladder neck incision in the treatment of small benign prostatic hyperplasia

From May 1986 to January 1989, a total of 178 patients with small prostate (less than 20 grams) received transurethral resection for benign prostatic hyperplasia. Twenty-two patients (12.4%) developed bladder neck contracture with an average interval of 247 days. The prophylactic bladder neck incision was performed concomitantly with transurethral resection of the prostate on 72 patients. Although smaller adenoma (average weight: 11.4 grams) was resected in this group, the bladder neck contracture occurred in 4 patients (5.6%), compared to 18 contractures in 106 patients (16.9%) who underwent transurethral resection of the prostate alone for larger adenoma (14 grams), P value less than 0.05. The operation time, peri-operative morbidity and hospital stay were similar in these two groups. It appeared that prophylactic bladder neck incision could protect against the formation of bladder neck contracture in patients with small obstructing prostatic adenoma.