Contact laser sphincterotomy: further experience and longer follow-up.
I report here the use of a crystal chisel contact tip firing Nd:YAG laser for transurethral sphincterotomy in 76 consecutive spinal cord injury patients. Their mean age was 53 years (range 26 to 77 years). Fifty-four (72%) were complete motor (Frankel A and B) and 21(28%) were incomplete lesions (Frankel C and D) They were evaluated with multichannel urodynamic equipment and 89% of the patients showed detrusor sphincter dyssynergia and 11% showed detrusor areflexia. Forty-three patients (56%) had previous electrocautery sphincterotomy and were not voiding well. A cystoscopic examination showed that 32% had an associated enlarged prostate and/or bladder-neck stenosis and 32% had associated wide-body strictures in the bulbous urethra. The crystal chisel contact tip firing Nd:YAG laser almost mimicked a hot diathermy knife to create an intraurethral incision as well as vaporizing the tissues. For sphincterotomy, a 12 o'clock incision was used from the verumontanum to the bulbous urethra. In patients with an associated enlarged prostate or bulging lateral lobes, 3 and 9 o'clock incisions were also made from the bladder-neck to the verumontanum and also vaporized the bulging prostate tissue. We used 25 to 40 watts for cutting, and vaporization of tissue and 15-25 watts to stop bleeding. The blood loss was less than 50 ml at surgery in 97.4% patients. None of the patients were transfused. An indwelling Foley catheter was usually left in situ for about 24 h and the majority of the patients were discharged the next day. All patients have been followed up at least every 6 months for a mean period of 27 months (range 16 to 41 months). The durability of surgery has been checked with linear array transrectal sonography and by urodynamic evaluation. Sixty-nine patients (92%) had adequate voiding, minimal to absent autonomic dysreflexia and no significant symptomatic urinary tract infection. There were seven patients who required repeat laser surgery within 2 to 5 months. All subsequent patients are voiding well with wide open bladder-neck and posterior urethra as shown on a voiding cystourethrogram.
Perkash
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I
Veterans Affairs Palo Alto Health Care System, California 94304, USA.
D000328:Adult; D000368:Aged; D003558:Cystoscopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053685:Laser Therapy; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000150:complications; D011182:Postoperative Care; D011467:Prostate / Q000601:surgery; D011782:Quadriplegia / Q000150:complications; D013119:Spinal Cord Injuries / Q000150:complications*; D014463:Ultrasonography; D014521:Urethra / Q000601:surgery*; D014524:Urethral Obstruction / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery; D014563:Urodynamics