- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
443
URinaRy inContinEnCE
urinary frequency, voided volume, UUI, number |
degree of peripheral denervation of the pelvic |
|||
of leakage episodes, pad usage, bladder capacity, |
floor striated musculature and the ability to |
|||
and quality of life. Literature supports the effi- |
void spontaneously or with self-catheterization |
|||
cacy of Botox at doses of 10 U per injection site |
(without electrical stimulation). Patient may |
|||
(total of 100–300 U). Procedure-related UTI are |
have transient discomfort at initial skin punc- |
|||
the most common side effects. The lowest mean |
ture site, but there is little pain with needle |
|||
duration of effect for Botox in patients with neu- |
advancement or delayed pain. Initial results of |
|||
rogenic detrusor overactivity was 5.3 months. |
posterior tibial nerve stimulation in 22 patients |
|||
Duration is typically ³6 months. Up to 16% of |
with primarily urgency and UUI revealed 80% |
|||
patients with idiopathic detrusor overactivity |
with at least a 75% reduction in incontinence |
|||
may need clean intermittent catheterization for |
and 45% to be completely dry. |
|||
several weeks after BTX treatment.63 In a multi- |
|
|||
institutional, randomized, |
double-blind, |
pla- |
Stress Urinary Incontinence |
|
cebo-controlled clinical trial comparing 200 U |
||||
|
||||
intra-detrusor BTX-A and placebo in women |
|
|||
with refractory idiopathic |
UUI, 60% |
who |
The International Continence Society (ICS) |
|
received BTX-A had a clinical response. BTX-A |
||||
defines SUI as the complaint of involuntary leak- |
||||
was effective and durable, yet 43% experienced a |
||||
age on effort or exertion, or on sneezing or |
||||
transient increase in postvoid residual.64 |
|
|||
|
coughing3 Unlike men who develop SUI follow- |
|||
Sacral nerve stimulation (SNS) or neuromod- |
ing an iatrogenic cause, SUI in women is an |
|||
ulation has been approved by the FDA for the |
||||
indolent process and may take much longer to |
||||
treatment of UUI since 1997. The mechanism of |
||||
present for management. |
||||
action remains unclear, yet numerous studies |
||||
|
||||
note long-term success and safety. SNS is usually |
Male SUI Therapies |
|||
performed in two stages: first a temporary or |
||||
permanent external lead is placed into the S3 |
Following prostate surgery or radiation, men are |
|||
foramen for external stimulation; and second a |
||||
subcutaneous impulse pulse generator is |
encouraged to attempt active conservative man- |
|||
implanted. A prospective, multicenter 5-year |
agement with fluid restriction, medication man- |
|||
trial of 163 patients (87% female) was performed |
agement(forurgencyandUUIrelatedsymptoms), |
|||
to assess the efficacy and safety of SNS. They |
and pelvic floor exercises. Parekh et al. reported |
|||
reported a significant decrease in mean leaking |
on pre-op pelvic floor exercises aiding in earlier |
|||
episodes per day (9.6 ± 6 to 3.9 ± 4) and no life- |
achievement of urinary continence, yet pro- |
|||
threatening or irreversible adverse events |
longed conservative management has question- |
|||
occurred.65 Sutherland et al.reported on 11 years |
able merit.67,68 Periurethral bulking agents are a |
|||
of experience with SNS performed in 103 |
minimally invasive treatment option for male |
|||
patients (87% female). Statistical significant |
SUI, but have extremely low cure rates, 5–8%.69-71 |
|||
improvement post implantation was noted in |
Surgical intervention is indicated for treating |
|||
leaks per 24 h and pads per 24 h. There was |
male SUI that is persistently bothersome despite |
|||
60.5% improvement based on quality of life.66 |
12 months of active conservative management. |
|||
Central sacral neuromodulation has been |
The severity of incontinence and magnitude of |
|||
successful in treatment of urgency and urge |
the effect on the patient’s quality of life is bal- |
|||
incontinence, yet a significant drawback is that |
anced against the risks of surgery. The male sling |
|||
placement of the stimulator is invasive, there is |
and artificial urinary sphincter (AUS) are the two |
|||
moderate complication rate, and up to 50% |
most common surgical procedures for the man- |
|||
require reoperation. Thus, various approaches |
agement of PPI.This choice is based on the sever- |
|||
to minimally invasive, peripheral transcutane- |
ity of leakage, comfort with implantation and |
|||
ous nerve stimulation (PTNS) have been tested, |
manipulation of an artificial device,patient phys- |
|||
including stimulation of the posterior tibial |
ical limitations, and need for continuous inter- |
|||
nerve and pudendal (dorsal penile/ clitoral) |
mittent catheterization.There are no prospective, |
|||
nerves. PTNS like SNS requires a cooperative |
randomized comparisons between these two |
|||
patient with a morphologically intact urinary |
modalities, yet both techniques have been stud- |
|||
tract, normal sacral spinal reflex center, limited |
ied and reported on extensively.72 |
|
|
444 |
|
|
|
|
|
PRaCtiCal URology: ESSEntial PRinCiPlES and PRaCtiCE |
The AUS was first introduced in 1973 and has |
or much improved. Rajpurkar et al. reported sat- |
|
undergone numerous redesigns to the present |
isfaction rates of 70% and 74% improvement in |
|
date. It circumferentially occludes the urethra |
leakage at a median of 24 months.80 There are no |
|
(usually bulbar urethra) with continuous com- |
reported cases of prolonged urinary retention |
|
pression,controlled by an intra-abdominal pres- |
or new onset UUI in the literature following a |
|
sure regulating balloon (IPG) (with 22 cm3 of |
male sling.70 The infection and erosion rates, |
|
normo-osmotic mixture at 61–70 cm water pres- |
2.1% and 4.2% respectively,79 are much lower |
|
sure). During voiding, activation of a scrotal |
than seen following AUS placement. There is |
|
pump diverts the compressive fluid from the |
limited published information on a new tran- |
|
cuff to the balloon reservoir, relieving the occlu- |
sobturator male sling. Thus far, reported data |
|
sive effects of the cuff on the urethra. Primary |
indicates a 40% success rate 6 weeks post-op.81 |
|
and double-cuff techniques have been utilized, |
The AUS and male sling are both contraindi- |
|
though double cuffs are associated with a higher |
cated for patients requiring transurethral sur- |
|
rate of erosion. Historically abdominal and |
gery, due to higher risk of erosion and infection. |
|
perineal incisions are made for placement of the |
Unlike the AUS, a patient’s pre-op detrusor con- |
|
IPG, cuff, and pump. There has also been success |
tractility must be considered prior to male sling |
|
with single scrotal incision approach for place- |
surgery. Detrusor hypocontractility is a con- |
|
ment of all three parts.73-77 In cases of an AUS |
traindication for the male sling due to the risk of |
|
revision for urethral atrophy or erosion, a |
increased outlet resistance leading to upper uri- |
|
transcorporeal approach may be used. With the |
nary tract damage. In patients with detrusor |
|
introduction of the narrow back cuff in 1987, the |
hypocontractility, AUS implantation is recom- |
|
success rates for the AUS are upwards of 90% in |
mended. In patients with previous AUS or male |
|
modern series for all levels of incontinence. The |
sling surgery, primary radiation therapy, or |
|
largest series to date, from the Mayo Clinic, |
severe or total incontinence, the AUS is pre- |
|
included 323 patients with a mean follow-up of |
ferred. The male sling is preferred in patients |
|
6 years and reported a 90% success rate. Their |
with poor manual dexterity or insufficient men- |
|
revision rate was 17% with a narrow back cuff.78 |
tal faculties to cycle AUS, those patients wanting |
|
Infection and urethral erosion are often related |
to spontaneously void without manipulation, |
|
and range from 0% to 25% when reported as a |
and those requiring intermittent catheteriza- |
|
single entity. When reported separately, infec- |
tion. The male sling is better selected in those |
|
tion rates with initial AUS surgery is 0–3%, and |
patients with mild SUI and good detrusor con- |
|
as high as 10% in patients who underwent radi- |
tractility due to a lower infection and revision |
|
ation therapy or in cases of repeat AUS surgery. |
rate.72 |
|
Revision rates are approximately 8% and 9% for |
|
|
nonmechanical and mechanical failure and |
Female SUI Therapies |
|
15–25% for recurrent ISD (from urethral atro- |
|
|
phy) at 5 years with the narrow-backed cuff.72,78 |
Patients and physicians can choose between |
|
The male sling was devised in response to the |
conservative, nonsurgical, pharmacological, and |
|
risks of infection and urethral erosion associ- |
surgical treatment options for female SUI. |
|
ated with the AUS, and to allow for voiding with- |
Conservative therapy is the first-line therapy, |
|
out device manipulation. The modern male |
especially when the SUI is less severe. Lifestyle |
|
sling has gone through many versions prior |
modifications such as weight loss, smoking ces- |
|
to the commonly used transperineal bone- |
sation, and fluid intake adjustments are often |
|
anchored, minimally invasive approach. Six |
initially recommended as early measures. Many |
|
titanium bone screws suspend a piece of sili- |
patients make these changes in order to cope |
|
cone-coated polyester mesh to the medial aspect |
with their condition.82 In addition, patients are |
|
of either descending ramus, creating approxi- |
encouraged to perform timed voiding,prompted |
|
mately 60 cm of water compression on the ure- |
voiding or bladder training, Kegel exercises, and |
|
thra. Two large prospective studies reported |
maintain a voiding diary. These measures ide- |
|
success rates of 70–80%. In the first, with a |
ally help increase effective bladder capacity. |
|
median follow-up of 48 months, symptom score |
Voiding logs are essential in understanding the |
|
and pad use were significantly improved.79 Two- |
patient’s fluid intake in relationship to their out- |
|
thirds were made pad free and 80% were cured |
put and the voiding interval. The log therefore |
445
URinaRy inContinEnCE
can act as a reminder to void (timed voiding) |
to urination. There is a meatal plate to prevent |
and also provide a schedule to increase their |
migration of the device into the bladder and a |
voiding interval. Fantl et al. reported a 57% |
string to enhance removal. Adverse effects |
reduction in incontinence episodes and a 54% |
include hematuria, UTIs, and discomfort.83,85 |
reduction in quantity of urine loss in older |
Pessaries or intravaginal support devices are |
women attempting conservative measures, |
often used for symptomatic prolapse, but may |
which was similar in patients with UUI and |
be used to treat SUI, especially in those patients |
SUI.83 Pelvic floor muscle training (PFMT) |
with mild to moderate anterior vaginal wall pro- |
incorporates repeated high-intensity, pelvic |
lapse, associated with hypermobility. Pessaries |
muscle contractions of both slowand fast- |
act by mechanically supporting the bladder |
twitch muscle fibers. PFMT is believed to |
neck.83 |
strengthen the pelvic floor muscles (PFM), par- |
There is no globally used or widely successful |
ticularly the levator ani, and enhance the ability |
pharmacological treatment available for SUI, |
to produce an increase in urethral resistance. |
due to the large variability in success rates and |
Combination therapies involving PFMT and |
significant adverse effects. Pharmacologic ther- |
adjuncts, such as vaginal cones, biofeedback, |
apy has included: a-adrenergic agonists, imip- |
and electrical stimulation, do not have addi- |
ramine, duloxetine, ß-adrenergic agonists and |
tional benefit, except to assist a woman to learn |
antagonists, and hormonal therapy. The bladder |
how to perform a correct PFM contraction.82,83 |
neck and urethra contain a large number of |
A multicenter trial of behavioral measures, |
a-adrenergic receptors that induce muscle con- |
PFMT, and combination therapy was conducted |
traction and increase outlet resistance. Multiple |
in 204 women over 3 months. The combination |
a-adrenergic agonists (phenylpropanolamine) |
arm reported significantly fewer incontinence |
have been tested with poor cure rates (0–14%) |
episodes, better quality of life, and greater treat- |
and side effects ranging from 5% to 33%.86 |
ment satisfaction. Yet, 3 months after comple- |
Caution must be utilized in patients with hyper- |
tion of the trial, there were no differences noted. |
tension, cardiovascular disease, or hyperthy- |
This confirms the importance of patient compli- |
roidism. Phenylpropanolamine was withdrawn |
ance and reinforcement in achievement of suc- |
from market after an increased risk of hemor- |
cess.84 Compliance is in fact the main drawback |
rhagic stroke was documented. TCA antidepres- |
of conservative therapy. |
sants have central and peripheral anticholinergic |
Nonsurgical, occlusive, or supportive devices |
effects at some sites, block the active transport |
are utilized in a group of women for manage- |
in presynaptic nerve endings preventing |
ment of SUI. There are some comfort issues |
reuptake of norepinephrine and serotonin, and |
related to size, suppleness of device, and patient |
act as a sedative. Imipramine theoretically |
willingness to manipulate their genitals to uti- |
decreases bladder contractility and increases |
lize these devices. Additionally, a number of the |
outlet resistance.83 In an open label study of imi- |
occlusive devices are single or disposable prod- |
pramine, a 35% cure rate by pad test and addi- |
ucts, making cost substantial. Sexual activity |
tional 25% subjective improvement was |
may be affected if the device needs to be removed |
reported.87 TCAs are associated with dry mouth, |
before or after coitus, resulting in inconvenience |
constipation,retention,orthostatic hypotension, |
and coital incontinence. Extra-urethral, intrau- |
and falls.33 |
rethral and intravaginal (pessaries) supportive |
Duloxetine was the first widely available phar- |
devices have been used. The extra-urethral |
macological treatment option licensed for the |
device (Miniguard®, FemAssist®, or CapSure™) |
treatment of SUI. Duloxetine is a combined |
must be removed prior to voiding.While subjec- |
serotonin and norepinephrine reuptake inhibi- |
tive and objective (pad test) outcomes have |
tor, with no affinity for neurotransmitter recep- |
shown slight improvement, there is associated |
tors. Duloxetine increases the concentration of |
transient vulvar and lower urinary tract irrita- |
both serotonin and noradrenaline in the synap- |
tion, vaginal irritation, and urinary tract infec- |
tic cleft in Onuf’s nucleus, which promotes |
tions. Single-use, disposable intraurethral |
enhanced activity of the striated urethral |
devices (FemSoft®) are inserted directly into the |
sphincter.83,88 Duloxetine appeared to have great |
urethra, obstructing the flow of urine into the |
promise on initial use, but has since shown on |
proximal urethra. They must be removed prior |
multiple studies to have high discontinuation |
|
|
|
446 |
|
|
|
|
|
|
PRaCtiCal URology: ESSEntial PRinCiPlES and PRaCtiCE |
|
rates from adverse effects. Vella et al. reported |
agents: UTI, hematuria, and transient elevation |
||
on 1-year follow-up of duloxetine treatment for |
of postvoid residuals.82,83 |
||
SUI in 228 women.Only 9% of patients remained |
Sling procedures can be divided into the clas- |
||
on duloxetine for 1 year and 82% had a tension- |
sic pubovaginal sling and the minimally invasive |
||
free vaginal tape. The majority of women dis- |
mid-urethral polypropylene sling. As opposed |
||
continued use due to adverse effects (56%) or |
to an urethropexy, sling surgery may not only |
||
lack of efficacy (33%).89Adverse effects include |
provide a “backboard” of support for the vesi- |
||
nausea, fatigue, dry mouth, insomnia, and sui- |
courethral junction, but also create some degree |
||
cidal ideation or behavior in individuals under |
of urethral coaptation or compression. The clas- |
||
the age of 24 years.83 |
sic sling is used for women with ISD and may be |
||
ß-adrenergic agonists (clenbuterol) may have |
used as a primary option or in patients who |
||
some efficacy through an action agonism result- |
failed initial anti-incontinence surgery. Slings |
||
ing in smooth muscle relaxation of the bladder |
should be tied at the bladder neck (after passage |
||
wall.Yasuda et al.90 reported on results of a dou- |
through the endopelvic fascia and behind the |
||
ble-blind, placebo-controlled trial with clen- |
pubic bone) with minimal or no tension to pre- |
||
buterol in 165 women in Japan and found |
vent bladder outlet obstruction (Fig. 32.3). |
||
significant improvement in frequency of incon- |
Historically, autologous rectus fascia and fascia |
||
tinence, pads per day, and overall global assess- |
lata are the most commonly used sling materi- |
||
ment of treatment. It is presently only approved |
als. Other materials that are used include: vagi- |
||
for SUI use in Japan. ß-adrenergic antagonists |
nal wall, human cadaveric tissue, xenograft, and |
||
theoretically enhance norepinephrine effects on |
synthetic materials. Long-term studies note cure |
||
a-adrenergic receptors in the urethra. Prop- |
rates greater than 80% and rates of improve- |
||
ranolol has shown some beneficial effect in |
ment of greater than 90%.92,93 Autologous mate- |
||
uncontrolled small numbers. This has not been |
rials are generally associated with higher cure |
||
reported in randomized, controlled trial.33,83 |
rates than cadaveric or synthetic materials.82,83 |
||
Estrogen receptors are present in the vagina, |
In the mid-1990s, the TVT was introduced for |
||
urethra, bladder, and pelvic floor, yet their role |
treatment of SUI. This is a minimally invasive |
||
remains controversial.Understanding estrogen’s |
option mainly used for women with urethral |
||
role is based on cytologic and clinical changes |
hypermobility. The TVT is passed through the |
||
observed after menopause and the high inci- |
retropubic space and aims to reinforce puboure- |
||
dence of incontinence reported by elderly, post- |
thral ligaments and secure proper fixation of the |
||
menopausal women. This literature has been |
mid-urethra to the pubic bone for maintenance |
||
reviewed extensively, and an evidence-based |
of continence. Three small incisions are made |
||
recommendation for the use of estrogens to |
(two suprapubic and one on the anterior vaginal |
||
treat SUI in women is not supported.4,33,83 |
wall at the mid-urethra).82 A prospective study |
||
Manysurgicalprocedureshavebeendescribed, |
comparing the TVT to the open Burch colposus- |
||
which can be divided into three types: urethral |
pension found the same effectiveness (TVT 81% |
||
bulking agents (injectables), suburethral sling |
and Burch 80%).94 Bladder perforation is the |
||
procedures, and colposuspension. Bulking |
most |
frequent intraoperative complication |
|
agents were initially described to treat SUI |
(intraoperative cystoscopy is required) occur- |
||
caused by ISD, but have since been found to have |
ring in 1 in 25 cases. Postoperatively, complica- |
||
applicability in urethral hypermobility also. |
tions |
include voiding difficulties, UTI, and |
|
Most periurethral agents are injected in a retro- |
de novo detrusor overactivity.82 The transobtu- |
||
grade fashion under direct cystoscopic guidance |
rator tape (TOT) was initially marketed to avoid |
||
with local anesthesia. Various agents (GAX col- |
the retropubic space and risk of bladder perfo- |
||
lagen, Teflon®, silicone, fat, cartilage, Coaptite®, |
ration associated with the TVT. Yet, there are |
||
Durasphere®) have been used to increase outlet |
numerous reports of bladder perforation with |
||
resistance. Each of these agents has variable bio- |
the TOT, making cystoscopy essential following |
||
physical properties influencing tissue compati- |
TOT placement. Three small incisions (two |
||
bility,tendency for migration,density,durability, |
groin incisions lateral to the inferior pubic |
||
and safety. Success rates range from 40% to 86% |
ramus and one vaginal incision in the mid-ure- |
||
with continuous decline in efficacy over time. |
thra) are made with the TOT. The complication |
||
There is low morbidity associated with bulking |
and cure rates are similar between the TOT and |
447
URinaRy inContinEnCE
a
Pubic
symphysis Urethra Cooper’s ligament Vagina
Bladder
Uterus
c
Rectus abdominis muscle
b
Tape
Sling
Figure 32.3. Surgical procedures for treating stress incontinence.(a) Burch colposuspension, (b) Fascial sling, (c) tension-free vaginal tape (Reprinted with permission from Rogers91. Copyright © 2008 Massachusetts Medical Society. all rights reserved).
TVT.95 While avoiding the retropubic space, the passage of the TOT poses risk to the obturator vessel tributary and adductor muscles. The TOT is associated with greater post-op groin/thigh pain (see Fig. 32.3).96 Recently, FDA-approved single-incision mid-urethral polypropylene slings (MiniArc™, TVT-SECUR™) have been introduced. Short-term data reveals results similar to the TVT or TOT, but long-term efficacy has not been determined.97
Transabdominal (retropubic) colposuspension has historically been the standard to correct SUI. The advantages include: familiar retropubic anatomy, exposure, durability, and ability to repair coexisting abdominal pathology. The disadvantages include: large incision, prolonged hospitalization and recovery, and inability to access coexistent vaginal pathology through the same incision. The Marshall-Marchetti-Krantz (MMK),Burch colposuspension,and paravaginal
(Richardson) repairs are the three most common types of open retropubic colposuspension procedures performed.83 They have excellent longterm success rates, in excess of 80% at 4 years post surgery.93 In the MMK, the space of Retzius is entered and the anterior bladder and urethra are mobilized. The periurethral fascia anterolateral to the urethra is sutured to the posterior periosteum of the symphysis pubis from midurethra to the bladder neck.83 This procedure is associated with a 2.5% risk of osteitis pubis and more likely to cause urethral obstruction than other anti-incontinence procedures.98 With Burch colposuspension, the tissue lateral to the bladder neck (paravaginal fascia) is suspended to Cooper’s ligaments bilaterally, supporting the vesicourethral junction within the retropubic space (see Fig. 32.3). These sutures are usually more proximal and lateral than the MMK sutures. The Burch procedure is considered less