Surgery for Female SUI: Old Versus New

J. G. BLAIVAS, Weill Medical College of Cornell University, New York, New York

Contemp Urol, 79–87, November 2000

No Abstract

Editorial Comment: This is a report of 2 roundtable discussions moderated by Blaivas (includ-ing Dmochowski, Klutke, Raz and Zimmern) on the variety of surgical procedures currentlyused to treat female sphincteric incontinence. You will be surprised (maybe not) to see thatthere was little unanimity regarding specifics having to do with even a “simple index case.”Perhaps the best part of the entire discussion was a well thought out summary statement madeby Appell after reading all of this, and I think this statement is worth noting: “. . .these super-stars in the field of female urology essentially all agree (as do I) that women suffering with stressincontinence have some degree of sphincteric incompetence. Additionally, they believe (as I do)that this is best treated by the placement of ‘something’ suburethrally, resulting in coaptation ofthe outlet without obstruction. After that, there are differing points of view regarding the bestsling material, the sling’s exact placement, how the sling should be fixed in position, how muchof the patient’s tissue should be disrupted during placement, and even how the patient’s urinaryoutput is best managed postoperatively.” “All of these viewpoints are both correct and incorrect,depending on the individual patient’s findings, which include symptoms, previous treatmentsand results, pelvic exam (including evaluation of hypermobility of the vesicourethral junction),and urodynamic testing. I personally do not do the same operation in every patient, but use allof the procedures discussed by the panelists as well as some others. The selection depends on myevaluation of the individual patient and my experience with the varying procedures in eachparticular subset of patients . . . .”

“This is the art of medicine at its best. We who work in this field on a daily basis keep tryingto make science out of this art. I hope that, some day, it does become a science. At that point intime, we will truly have made some headway in the successful management of female stressincontinence. For now, we and our patients will have to be content with about an 80% to 85%success rate regardless of the surgeon and the specifics of the sling he or she chooses.”

Alan J. Wein, M.D.

TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION

CT Evaluation of Renovascular Disease

A. KAWASHIMA, C. M. SANDLER, R. D. ERNST, E. P. TAMM, S. M. GOLDMAN AND E. K. FISHMAN, Departments ofRadiology and Urology, University of Texas Medical School and Department of Radiology, Lyndon B.Johnson General Hospital, Houston, Texas, and Russell H. Morgan Department of Radiology and Radio-logical Science, Johns Hopkins Medical Institutions, Baltimore, Maryland

Radiographics, 20: 1321–1340, 2000

Computed tomography (CT) plays an important role in evaluation and management of primary renovas-cular disease. Nonenhanced CT is useful for demonstrating renal hemorrhage, renal parenchymal orvascular calcifications, and masses. Contrast material-enhanced CT is essential to identify global orregional nephrographic abnormalities resulting from the vascular process (eg, renal infarcts, ischemiasecondary to renal artery stenosis, arteriovenous communications). In addition, renal manifestations of asystemic disease (eg, vasculitis, thromboembolic disease) can be seen at CT. In trauma, occlusion of the mainrenal artery can be accurately diagnosed with contrast-enhanced CT. In cases of spontaneous renalhemorrhage without an apparent cause (eg, vasculitis, coagulopathy), a careful CT study should beperformed to exclude renal cell carcinoma. The presence of fat in a hemorrhagic renal mass larger than 4cm in diameter is characteristic of angiomyolipoma complicated by hemorrhage. Acute renal vein throm-bosis appears as a clot in a distended renal vein, whereas renal vein retraction with collateral vessels ishighly indicative of chronic thrombosis. Helical CT, especially with multiplanar two-dimensional andthree-dimensional reconstruction following an intravenous injection of iodinated contrast material, hasgreatly improved our ability to directly image the proximal renal arteries and detect vascular lesions.

Editorial Comment: In this report on CT evaluation of all aspects of renovascular disease theauthors include exceptionally illustrative images and describe in detail relevant pathologicalfindings and contemporary management. The discussions and illustrations related to traumaticrenal injury are superb and accurate. The ability of CT to detect renal arterial injury isemphasized since the early vascular phase of a contrast spiral CT can delineate clearly the exact

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site of an intimal flap, and the helical reconfiguration in this study can facilitate greaterprecision in the diagnosis. Segmental renal artery injuries and pseudoaneurysms can be de-tected clearly in these studies. This concise, informative and up-to-date report should be read byall urologists, radiologists and trainees in both specialties.

Jack W. McAninch, M.D.

Q-Flap Reconstruction of Panurethral Strictures

A. F. MOREY, L. K. TRAN AND L. M. ZINMAN, Brooke Army Medical Center, Fort Sam Houston, Texas, andLahey Clinic Institute of Urology, Burlington, Massachusetts

BJU Int, 86: 1039–1042, 2000

Objective To review our experience with an extended Q-shaped penile skin flap for the reconstruction ofpanurethral strictures.

Patients and methods Between 1991 and 1999, 15 men with extensive strictures underwent a single-stageurethral reconstruction with a distal circumferential penile skin flap incorporating a ventral midlineextension (Q-flap). None had undergone previous urethroplasty nor had any been circumcised.

Results The Q-flap provided a pedicled strip of penile skin with a mean (range) length of 17 (15–24) cm;no additional graft materials were necessary. Excellent results were obtained in 10 patients; in theremainder, complications included recurrent stricture (in two) and (in one patient each) a cerebral vascularaccident, urethrocutaneous fistula, meatal stenosis, femoral neuropathy and prolonged catheterization forfocal extravasation.

Conclusion The Q-flap provides an abundant hairless penile skin flap that enables single-stage panure-thral reconstruction while eliminating the additional time and morbidity of harvesting further grafts.

Editorial Comment: This article reflects the advances being made in the field of urethralreconstructive surgery. The authors report a modification of the circular fasciocutaneous flap,which is a technique for single stage urethral reconstruction of extensive panurethral stric-tures, that extends the circular penile flap down the ventral portion of the penile shaft. Usingthis technique in 15 patients with complex stricture disease excellent results were noted. Themean length of the developed flaps was 17 cm. (range 15 to 24). This vascularized island flaptechnique has been successful in my experience. The authors note the extreme labor-intensiveness and potential complications of this method, for example from the sequelae ofpositioning to loss of penile skin, and suggest that special training or experience in complexurethral reconstruction is a great advantage.

Jack W. McAninch, M.D.

BOOK REVIEWS

Textbook of Prostatitis

J. C. NICKEL, Oxford: Isis Medical Media Ltd., 375 pages, 1999

This text is the first multiauthored compendium concerning all aspects of prostatitis and the chronicpelvic pain syndrome in men since Prostatitis, edited by Weidner et al, in 1994. The title is a bit misleading,suggesting that the book is about prostatitis infections. At least half is devoted to the new NationalInstitutes of Health classification of chronic pelvic pain syndrome types 3a and 3b, which were previouslytermed nonbacterial prostatitis and prostatodynia. Since cases of pelvic pain syndromes constitute a largepercentage of urological outpatient visits, this book is a valuable resource for physicians who treat men withprostatic infection and pelvic pain. The text is generally easy to read, featuring large print and excellentillustrations and tables. This book is excellent bedtime reading as well as an authoritative, up-to-datesource to help answer questions from increasingly savvy patients.

The text is divided into several sections. The introduction contains a chapter written by a patient, whichclearly shows the frustration of those who believe they have an infection that no one can diagnose. Sincethere is conflicting and confusing evidence that most cases of prostatitis are infection related, this chapteris especially poignant. Also included is an explanation of the new National Institutes of Health classifica-tion, which differs from the previous classification only in verbiage.

The basic science section is an excellent review and is well illustrated. Topics covered include the anatomyand physiology of the prostate gland. There are 2 excellent chapters on the neurophysiology of the prostateand pelvic floor as well as 2 chapters on microbiology and antibiotics. Knowledgeable authors present 13chapters on the epidemiology, etiology and pathogenesis of prostatitis. The chapters are a little heavy onmicrobiology in view of newer research developments on the roles of the central and peripheral nervous

BOOK REVIEWS 2155