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11/29. An outlet obstruction caused by V-shaped bar at the bladder neck in a woman.

    A case of outlet obstruction caused by a V-shaped bar at the bladder neck in a woman was treated successfully by transurethral resection of the bar. The poor urinary flow in our patient was believed to be due to impedance during voiding caused by retraction of the bladder neck in the anteroposterior direction by the bar. Our case is different from previously reported cases.
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12/29. Inverted Y duplication of the ureter in association with ureterocele and bladder diverticulum.

    We report a case of inverted Y duplication of the ureter in association with an obstructing ectopic ureterocele and paraureteral diverticulum. Preoperative radiological studies demonstrated the ureterocele and diverticulum but they failed to show the duplex distal ureter. The duplicated section of ureter was excised and a Cohen reimplantation was performed. The presence of a large ureterocele obstructing the bladder neck, a diverticulum, failure of reflux into the ectopic segment and poor function of the affected kidney all contributed to the difficulties in establishing a preoperative diagnosis.
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13/29. Bladder neck obstruction secondary to Brunn's cyst.

    A large solitary Brunn's cyst caused a ball-valve type of obstruction of the bladder neck in a 29-year-old man without endoscopic or histological evidence of bladder inflammation. Unroofing and drainage restored normal voiding. The histopathological features of Brunn's nests are reviewed.
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14/29. Primary lymphoma of prostate presenting as bladder outflow obstruction.

    We report on a patient with prostatic lymphoma who presented with symptoms of bladder neck obstruction. biopsy specimens from transurethral resection confirmed the diagnosis of prostatic lymphoma. There was no evidence of lymphoma spread. Treatment was by local x-ray therapy to the prostate gland. Since prostatic lymphoma is rare, the clinical literature is briefly reviewed.
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15/29. Corticosteroids in treatment of obstructive lesions of chronic granulomatous disease.

    Two patients with chronic granulomatous disease had obstructive lesions of the gastrointestinal tract, esophagus, and genitourinary tract, which were successfully treated with corticosteroids. These obstructive lesions, caused by local granuloma formation, have been reported in 18 other patients with chronic granulomatous disease, none of whom received steroids. Our first patient, a 3-year-old boy, had emesis and weight loss associated with antral narrowing and delayed gastric emptying at age 2 years. Antibiotic therapy was ineffective, but intravenous and oral corticosteroid therapy for 10 weeks resulted in clinical cure. One year later, dysuria associated with bladder neck obstruction was also treated successfully with corticosteroids. The second child, a 10-year-old boy, had dysphagia caused by distal esophageal stenosis. Corticosteroid therapy (with concomitant antibiotics) on two occasions reversed this obstruction. Granulomatous cystitis with ureteropelvic obstruction then developed, which also responded to treatment with corticosteroids and antibiotics. Despite the risk of increased susceptibility to infection, corticosteroid therapy is justified in preventing life-threatening obstruction of vital organs.
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16/29. Bladder neck obstruction in women.

    Bladder neck obstruction in women is rare. The symptoms are confounding and nonspecific. The diagnosis depends on demonstrating poor uroflow, a detrusor contraction of adequate magnitude and duration, and radiographic evidence of obstruction at the vesical neck. We treated successfully 3 women with vesical neck obstruction by transurethral vesical neck incision.
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17/29. Mid-trimester diagnosis of bladder neck obstruction by ultrasound and paracentesis.

    A bladder neck obstruction was suspected after ultrasound investigation at 16 weeks' gestation. Evaluation of protein content in the amniotic fluid, fetal ascites, and fluid from the overdistended bladder supported the diagnosis. Bladder outflow obstruction in the second trimester of pregnancy was not associated with raised alphafetoprotein levels in the amniotic fluid and maternal serum.
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18/29. Intermittent catheterization failure and an approach to bladder rehabilitation in spinal cord injury patients.

    Forty-six patients with spinal injury with dysfunctional neurogenic bladder were analyzed. Fourteen patients on prolonged intermittent catheterization from 12 weeks to more than 1 year did not develop a balanced bladder, 14 patients had indwelling catheters after intermittent catheterization failed elsewhere and 18 patients on external condom drainage presented with difficult voiding and repeated infections. There were 16 quadriplegics (1 incomplete), 21 paraplegics, and 9 incomplete cauda equina lesions. Urologic and urodynamic evaluation revealed detrusor-sphincter dyssynergia in 15 patients, vesicoureteral reflux in 10, and areflexic bladders in 11. Five patients over the age of 55 years showed slight enlargement of the prostrate. Some degree of bladder neck fibrosis was suspected in 26. More than one urologic pathology was encountered in the same patient. Transurethral sphincterotomy was carried out in 38 patients and only one transurethral resection of the prostrate (TURP) in an incomplete quadriplegic patient. In seven patients with no obvious urodynamic abnormality, a balanced bladder was achieved with intermittent catheterization; however, one of these patients needed a transurethral sphincterotomy on subsequent admission. A balanced bladder was achieved in all patients except the one with incomplete quadriplegia. Significant improvement in vesicoureteral reflux and relief from autonomic dysreflexic symptoms were recorded in all patients.
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19/29. diverticulum of the urinary bladder.

    Vesical diverticulum predominates in males and is frequently associated with obstruction at or near the bladder neck. The obstruction may be due to benign prostatic hypertrophy, urethral stricture or, less often, carcinoma. diagnosis is made by intravenous or retrograde cystogram. Urinary stasis leads to recurrent infection and stone formation. While small diverticula may often be left alone, large ones should be surgically removed.
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20/29. Transurethral urethrotomy under vision.

    Transurethral urethrotomy under vision with the Sachse urethrotome is a new surgical procedure for the treatment of urethral strictures. The chief advantage of the urethrotome is the fact that the surgeon can cut strictures selectively and accurately under clear vision. The procedure is less painful than blind internal urethrotomy and less extensive cases can be done in the office with the patient under local anesthesia. We report on 36 cases with at least 6 months of followup. In 20 cases the strictures were distal to the prostate and the results were considered good in 16, improved in 3 and a failure in 1. The other 16 cases involved vesical neck contractures and all patients had good results. The technique for urethral strictures distal to the prostate and for vesical neck contractures is described and postoperative treatment is emphasized and discussed.
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