- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
118 CHAPTER 4 Incontinence
Treatment of sphincter weakness incontinence: pubovaginal slings
Indications
Sling procedures were developed mainly for female stress incontinence associated with poor urethral function (type III or ISD) or when previous surgical procedures have failed. The success of sling procedures, however, has resulted in expanded applications in women with hypermobility. It is essential that urethral and bladder function is evaluated prior to surgical repair.
Types of sling
•Autologous—rectus fascia, fascia lata (from the thigh), vaginal wall slings
•Nonautologous—allograft fascia lata from donated cadaveric tissue
•Synthetic—monofilament “macropore” polypropylene mesh (via transobturator, transabdominal, or transvaginal needles)
Autologous and allograft slings
The tissue strip is inserted via an abdominal incision and tunneled through the endopelvic fascia on one side, behind the proximal urethra and into the anterior vagina, and then guided out the other side. The two ends are sutured to rectus fascia, using the minimal amount of tension needed to prevent urethral movement. Alternative methods of fixation include bone anchoring; however, this is associated with increased risk of osteitis pubis.
Synthetic slings
Synthetic slings have become extremely popular worldwide—these procedures are less invasive, can be inserted under local anesthetic as a day case, and have few complications. The slings are inserted using either suprapubic (TVT™, SPARC™) or transobturator (Monarch™, TVT-O™) needles and tunneled into a mid-urethral location. “Macropore” polypropylene slings have been widely recognized as being more resistant to infectious complications
Cystoscopy is often used to detect bladder perforation during sling placement. Postoperatively, patients may temporarily require ISC until post-void residuals are <100 mL.
Outcomes
Overall, long-term cure rates for slings are 80%, with improvement seen in 90%.1 Complication rates are low but include voiding disorders (urinary retention, de novo bladder overactivity); vaginal, urethral, and bladder erosions; bowel and bladder perforation; and pelvic bleeding.
<?> 1 Abrams P, Cardozo L, Khoury S, et al. (Eds.) (2002) Incontinence, 2nd International Consultation on Incontinence, 2nd ed, Health Publications Ltd, pp. 825–863.
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120 CHAPTER 4 Incontinence
Treatment of sphincter weakness incontinence: the artificial urinary sphincter
The artificial urinary sphincter (AUS; AMS800™) consists of an inflatable cuff placed around the bulbar urethra in men, via either a perineal or high scrotal incision. Good coaptation of the cuff around the proximal corpus spongiosum provides the best outcomes.
Other components include a pressure-regulating balloon placed extraperitoneally, and an activating pump placed in the scrotum. The cuff, when activated, provides a constant pressure to compress the urethra. To void, the pump is squeezed, which transfers all fluid to the reservoir balloon, thereby deflating the cuff. The cuff then automatically refills within 3 minutes. Voiding takes place in the interval taken for the cuff to refill.
In women, a lower abdominal incision (midline or Pfannenstiel) may be used to place a cuff around the bladder.
Indications and patient selection
Indications include incontinence secondary to urethral sphincter deficiency in patients with normal bladder capacity and compliance. In men, it is used almost always for sphincter damage due to prostatectomy (radical prostatectomy for prostate cancer or TURP). In women it can be used for neuropathic sphincter weakness (e.g., spinal cord injury, spina bifida) if the incontinence is not due to bladder overactivity.
If there is combined bladder overactivity and sphincter weakness, treat the bladder first (i.e., trial of anticholinergics)—in some cases this will be enough to achieve continence. If incontinence persists, proceed with AUS at a later date.
Good manual dexterity is required to manipulate the pump. Patients must also have sufficient cognitive function to operate the sphincter by themselves, several times daily.
Patient evaluation
Patients should undergo a careful history and physical exam to evaluate voiding function and severity of incontinence. Although urodynamics and/ or cystoscopy are often used to further identify anatomical abnormalities within the lower urinary tract in complex cases, “garden variety” SUI can often be diagnosed reliably on the basis of careful history and physical alone.
Results
An AUS can function well for many years. Overall long-term success (continued continence, no device malfunction) is 80%. Revision rates are about 20%, usually due to subcuff atrophy.
TREATMENT OF SPHINCTER WEAKNESS INCONTINENCE 121
Complications and long-term outcomes
Recurrent incontinence
This is secondary to urethral atrophy under the cuff (10% over the first 5 years post implantation); mechanical failure; urethral erosion (due to chronic pressure/ischemia from the cuff, often due to urethral catheterization during nonurological procedures without prior cuff deactivation); bladder overactivity or reduced compliance causing reflux; hydronephrosis; and renal failure.
Investigate recurrent incontinence by cystoscopy (to exclude erosion) and urodynamics (to detect high bladder pressures).
Erosion
Erosion is most common at 3–4 months, with 75% occurring in the first year. Patients present with pain and swelling of the scrotum, sudden worsening of incontinence, UI, and bloody discharge. Cuff erosion usually occurs if the AUS is not deactivated during catheterization or instrumen- tation—this dreaded complication results in prompt surgical removal of the entire device.
Use of an indwelling urethral catheter for more than 24 hours should be avoided in men with an AUS to prevent erosion—if long-term urinary diversion is required, consider SP tube placement.
Infection
Primary implant infection rates are 1–3%. With infection or erosion, remove the entire device and wait 3–6 months before reinsertion.
Salvage of an infected AUS may be accomplished via removal of the infected device, followed by copious washout with antiseptic solutions and immediate replacement with a new device