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1/29. Single system ureteral ectopia in boys associated with bladder outlet obstruction.

    PURPOSE: Ureteral ectopia is frequently associated with dysplasia of the associated renal segment in girls with ureteral duplication. However, single system ureteral ectopia is an uncommon anomaly more frequently noted in boys. We report on 6 boys with single system ureteral ectopia into the prostatic urethra above the verumontanum, who presented with radiological and clinical findings of bladder outlet obstruction. MATERIALS AND methods: Antenatal ultrasound in 3 boys demonstrated renal abnormalities and postnatal studies suggested the diagnosis of posterior urethral valve obstruction. Older boys presented with symptoms suggestive of bladder outlet obstruction. RESULTS: An ectopic ureter inserting into the prostatic urethra was noted in all 6 boys. The distal ureter was dilated elevating the bladder neck causing outlet obstruction. Surgical management consisted of nephrectomy and transurethral endoscopic incision of the distal ureter or nephroureterectomy with reconstruction of the prostatic urethra. In 2 younger boys voiding dysfunction with inability to empty developed. CONCLUSIONS: Single system ectopic ureters in boys may present with symptomatic and radiological findings resembling posterior urethral valves. Surgical treatment should include nephroureterectomy with reconstruction of the hypoplastic prostate. Some patients may have later voiding dysfunction.
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2/29. Endoscopic treatment of complete bladder neck obstruction by transurethral Seldinger technique.

    Bladder neck contracture is usually a complication of prostatectomy and the treatment of choice in such a condition should be endoscopic surgery. However, in a few patients the bladder neck may be completely obstructed preventing retrograde access into the bladder. A case is presented of complete bladder neck obstruction occurring after transurethral resection of prostate, which was treated after an access was provided by using transurethral Seldinger technique.
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3/29. New modality for treatment of resistant anastomotic strictures after radical prostatectomy: UroLume urethral stent.

    A new approach for the treatment of vesicourethral anastomotic stricture after radical retropubic prostatectomy is presented. The patient had failed treatment with bougies, balloon dilation, and cold-knife incision of the anastomotic area. Transurethral resection of the bladder neck resulted in a rapid recurrence of the stricture. He was successfully treated with insertion of a UroLume urethral stent. After 18 months of follow-up, the patient is symptom free.
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4/29. Bladder neck obstruction in the female.

    Bladder neck dysfunction is a rare cause of obstruction in women. The symptoms are nonspecific and diagnosis relies on video-urodynamic evaluation. In this case study, a woman presented with urinary retention, recurring urinary tract infections, and bilateral hydronephrosis, in whom video-urodynamics revealed bladder neck obstruction. Her clinical presentation, as well as the pertinent literature on the diagnosis and treatment of bladder neck obstruction in women, are reviewed.
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5/29. Long term complications of the intraprostatic spiral. Case report.

    A 76-year-old man had an intraprostatic spiral inserted to relieve bladder outlet obstruction that was caused by benign prostatic hypertrophy. After 30 months numerous complications had arisen including severe encrustations, urethral stricture, and sclerosis of the bladder neck. Regular replacement of the spiral or close monitoring of the development of encrustations seem necessary. The distal tip and the plating of the spiral require improvement.
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6/29. Giant stercoral stone and catheterization difficulty.

    An unusual case of giant calcification in the midline of the pelvis is reported herein. An 84-year-old male, whose urination was managed by clean intermittent self-catheterization (CIC), presented with catheter insertion difficulty. The patient had a history of transurethral operations for benign prostatic hyperplasia and small bladder stones. kidney, ureter and bladder (KUB) X-ray of post-enhanced computed tomography (CT) suggested a giant ball-shaped calcification in the bladder. A recurrent bladder stone was suspected. However, pelvic CT scan revealed that the giant calcification was, in fact, situated in the rectum. Thus, a diagnosis of giant stercoral stone was made. After the stone was removed manually, the patient had no difficulty in inserting the catheter. His prior complaint may have been caused by urethral bladder neck obstruction due to the giant stercoral stone.
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7/29. Intraoperative catheter management during laparoscopic excision of a giant bladder diverticulum.

    BACKGROUND: Massive bladder diverticula present a technical challenge to the laparoscopic surgeon. We describe a laparoscopic approach to transperitoneal diverticulectomy, using a specific catheter arrangement to allow excellent control of the various portions of the procedure. methods: A 49-year-old male with longstanding frequency was diagnosed with a 1000 cc bladder diverticulum and bladder neck outlet obstruction. Laparoscopic transperitoneal diverticulectomy was performed using a triple catheter arrangement: endoscopic placement of a Councill catheter in the diverticulum, fluoroscopic positioning of an occlusion balloon catheter in the renal pelvis, and placement of a Cope loop suprapubic tube. Additionally, a transurethral incision of the prostate was performed. RESULTS: The procedure was completed laparoscopically using a four port transperitoneal approach. During the procedure, the diverticulum could be filled and emptied as needed; the catheter across the diverticular neck facilitated subsequent closure of the bladder wall defect. The diverticulum was completely excised. The remaining defect in the bladder was then closed in 2 layers. The patient was discharged on postoperative day 3. CONCLUSION: Careful planning and arrangement of catheters in the bladder, ureter, and diverticulum facilitates laparoscopic transperitoneal diverticulectomy of even a very large volume diverticulum.
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8/29. When the sling is too proximal: a specific mechanism of persistent stress incontinence after pubovaginal sling placement.

    OBJECTIVES: To review a series of patients with persistent stress urinary incontinence (SUI) after pubovaginal sling (PVS) placement because of an excessively proximal position of the graft on the bladder neck. methods: Four women, who had previously undergone PVS placement for SUI, presented for evaluation of persistent SUI. All underwent investigations, including history, symptom questionnaire, quality-of-life assessment, physical examination, voiding cystourethrography, and multichannel urodynamic studies. Subsequently, takedown of the primary PVS and placement of an autologous fascial PVS were performed on all patients. A detailed case review of one of the patients is presented. RESULTS: All patients had persistent severe SUI confirmed by a positive supine stress test and Valsalva leak point pressure determination. Malposition of the graft was diagnosed preoperatively on the basis of severe distortion of the bladder base and a wide-open bladder neck at rest on the lateral standing voiding cystourethrography images. The diagnosis was confirmed on operative exploration. All patients were continent after takedown of the prior PVS and placement of an autologous fascial sling. CONCLUSIONS: Persistent SUI after PVS placement may occur secondary to positioning of the graft excessively proximally on the bladder neck. True lateral voiding cystourethrography views are essential for the precise diagnosis. In our experience, optimal management involves takedown of the primary PVS and placement of an autologous fascial PVS.
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9/29. Incomplete bladder duplication presenting antenatally.

    We report a case of an incomplete bladder duplication diagnosed by prenatal ultrasonography at 35 weeks of gestation. The patient was followed until bladder neck obstruction and high-grade vesicoureteral reflux of a solitary kidney prompted definitive repair at 6 months of age. Bladder duplication is a rare anomaly. To our knowledge this is the first documented case of an incomplete bladder duplication discovered antenatally.
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10/29. Acute urinary retention caused by a large peritoneal inclusion cyst: a case report.

    BACKGROUND: Pelvic masses have been known to cause bladder symptoms and compression. This is the first documented case of a large peritoneal inclusion cyst causing acute urinary retention from bladder outlet obstruction. CASE: A 36-year-old woman, gravida 2, para 2, presented to the gynecology clinic with an indwelling Foley catheter that was placed at an outside hospital secondary to acute urinary retention. Computed tomography, performed several days earlier for complaints of progressively worsening lower abdominal and pelvic pain, revealed a 10-cm, complex, cystic mass within the pelvis between the rectum and sigmoid colon, with anterior displacement of the bladder. The patient's past surgical history included a total abdominal hysterectomy as well as separate exploratory laparotomy for resection of a 20-cm peritoneal inclusion cyst and a prophylactic bilateral salpingo-oophorectomy. Due to the acute urinary retention and worsening pain, the decision was made to proceed with laparoscopic removal and drainage of the mass, which turned out to be consistent with a recurrent peritoneal inclusion cyst. Symptom relief was immediate. CONCLUSION: A large, recurrent, peritoneal inclusion cyst obstructed the bladder neck and presented as acute urinary retention. laparoscopy relieved the symptoms.
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