Bladder Blood Flow and De-Obstructive Open Prostatectomy: Correlation with Clinical and Urodynamic Parameters

PURPOSE

To assess the relation between tissue blood flow changes during surgery with clinical and urodynamic parameters in obstructed patients.

MATERIAL AND METHODS

A prospective study was conducted in 18 symptomatic patients with bladder outlet obstruction undergoing retropubic prostatectomy. A symptom assessment and a preoperative urodynamic study were performed. To measure bladder blood flow a BLF-10 laser Doppler flowmeter and a blunt-tipped probe were used intraoperatively. Tissue flow was measured in TPU units (1 TPU unit=1 ml per minute per 100 mg of tissue). Six measurements were taken: two control in the rectus abdominis muscle and four in the detrusor, two before the incision of the prostatic capsule and two after closure. For the statistical analysis, Wilcoxon test and a regression analysis were performed.

RESULTS

Mean age was 70 years (range: 56-84). Six patients had an episode of acute urinary retention (AUR). No differences were found in the initial and final values of bladder blood flow of the rectus muscle and the bladder dome. A decrease of bladder blood flow in the anterior bladder wall was observed after prostate enucleation. AUR patients showed no differences in bladder blood flow values. Bladder blood flow (BBF) changes showed no correlation with any urodynamic or clinical parameter.

CONCLUSIONS

Laser Doppler flowmetry is useful to study BBF with low morbidity, ease of use and reproducibility. Following de-obstructive surgery, a decrease in BBF occurs, probably associated with surgery. These changes are similar in patients with and without AUR and show no correlation with other parameters studied.

Urodynamic evaluation and management prior to renal transplantation

OBJECTIVES

To evaluate the indications for urodynamics studies (UDS) previous to renal transplantation (RT) and the results of bladder cycling (BC), performed in selected cases.

METHODS

Among 475 RT, 33 patients (6.9%) required UDS according our protocol. Indications were: (1) low urinary tract symptoms (LUTS); (2) defunctionalized bladder (DB), and (3) complex urologic history (reflux, neurogenic bladder, urethral valves, etc.). DB was defined as a total urinary output of <300 ml/24 h. Patients with DB underwent BC through a suprapubic catheter, undergoing UDS after BC. The rate and type of urodynamic anomalies were compared among the 3 groups. Cystometric capacity (CysCap) and compliance were evaluated according to the etiology of renal failure, diuresis, and number of previous bladder surgeries.

RESULTS

Fifteen patients (45%) showed abnormal UDS, Increased pressure at cystometry was the most frequent finding (46%). The rate of abnormal UDS among the 3 groups was not statistically significant (66.6% in DB, 42.8% in LUTS, and 35% in those with complex urologic history). Compliance and CysCap were significantly lower in the patients with DB, showing a significant correlation with diuresis. These parameters did not correlate with the number of previous bladder surgeries. BC resulted in normal UDS in 3 patients (33%) and a change in diagnosis in 2 patients (22%).

CONCLUSION

Our indications gave a good diagnostic yield. Patients with DB represent a group with different urodynamic findings. BC provides a more precise diagnosis or normalization of UDS in some cases.

The reliability of cysto-urethrographic signs in the diagnosis of detrusor instability in children

OBJECTIVE

To assess whether the signs associated with detrusor instability (DI), as assessed by video-urodynamic studies, can be evaluated by conventional voiding cysto-urethrography (VCUG).

PATIENTS AND METHODS

Fifty-nine children who underwent cystometry and VCUG were reviewed and divided into two groups; group 1 comprised 51 neurologically normal children who had DI (47 girls and four boys, mean age 7.9 years, range 4-14), with no malformations or previous surgery. Most had mixed symptoms, including urinary tract infections (44) and nocturnal enuresis with daytime symptoms (20); group 2 (control) comprised eight children (seven girls, mean age 9.7 years, range 6-15) with a stable bladder and the same clinical presentation. The interval between VCUG and cystometry ranged from 1 day to 5 months (mean 47 days) and was similar in both groups. Signs considered suspicious of DI were sought in the findings of VCUG.

RESULTS

In group 1, VCUG was normal or showed no specific signs (only vesico-ureteric reflux or vaginal voiding) in 25 (49%) of patients, whereas 26 (51%) had some signs suspicious of DI. Suspicious signs were urethral ballooning (in 11), bladder trabeculation or a constricting ring (eight), a 'spinning-top' urethra (three), urethral notching (two) and Mercier's bar (one). In group 2, five patients had no abnormal findings on VCUG and three had suspicious signs. The positive predictive value of VCUG was high (0.89) but the diagnostic yield of suspicious signs was low, because the sensitivity (0.5), specificity (0.62) and overall accuracy (0.52) were low.

CONCLUSION

Radiological signs suspicious of DI cannot be regarded as such in conventional VCUG, as although they were detected in half the patients with DI, they also occurred in three of eight children with a stable bladder.

Collagen for female genuine stress incontinence after a minimum 2-year follow-up

OBJECTIVE

To evaluate the medium-term outcome of gluteraldehyde cross-linked (GAX) collagen in the treatment of genuine stress incontinence in women.

PATIENTS AND METHODS

The study comprised 111 women (age range 33-90 years) with genuine stress incontinence who were treated with para-urethral collagen injections between 1990 and 1995. The patients were followed prospectively and their clinical outcome documented. Pre- and post-operative urodynamic data were examined to determine any prognostic indicators.

RESULTS

The overall results at a minimum 2-year follow-up (mean 3.3) showed 25% of patients to be dry and a further 40% improved. Although there were significant changes in some urodynamic values, no predictive factors of success were identified. Previous surgery for stress incontinence did not influence the final outcome.

CONCLUSION

Para-urethral collagen injection is a safe and relatively simple procedure with acceptable results at the medium-term follow-up. It could be offered as a primary or secondary procedure to women with genuine stress incontinence who are unable or unwilling to undergo surgical treatment. Objective urodynamic assessment revealed no factors of prognostic significance.

[Ingelman intervention (transvaginal bladder denervation) with treatment of bladder instability]

OBJECTIVES

To evaluate the clinical and urodynamic results achieved by transvaginal bladder denervation (the Ingelman technique) for bladder instability refractory to anticholinergic therapy.

METHODS

The Ingelman procedure was performed in 14 female patients in whom anticholinergic therapy was unsuccessful or contraindicated. The mean age was 53.3 years (range 21-71 yrs.) and the most common presenting symptom was urge incontinence. Bladder instability persisted in 7 patients (involuntary contractions throughout the filling phase), bladder compliance was less than 30 ml/cm H20 in 7 and bladder capacity less than 300 ml in 8 patients.

RESULTS

There were no intra or postoperative complications. The mean postoperative follow-up was 10.9 months (range 2-41). One patient was lost to follow-up.

CLINICAL RESULTS

10 patients (71%) reported cessation or decrease of symptoms ('clinical improvement'), 2 referred the same symptoms and 1 claimed to be worse. Urodynamic results: Some urodynamic parameters had improved in 6 of the 10 patients with clinical improvement; however, only 3 had a normal urodynamic study. Some urodynamic parameters (bladder capacity, compliance and first micturition sensation) had become worse in the 3 patients that showed no clinical improvement. There was no statistically significant improvement of the mean values of any urodynamic parameter.

CONCLUSION

Transvaginal bladder denervation is a simple and safe procedure. In this series, it has achieved symptomatic improvement in 70% of patients with bladder instability. Urodynamic improvement was observed in only 3 of these patients (21%). Patients with no clinical improvement also showed worse urodynamic data postoperatively.

Polytetrafluoroethylene sling for failure in female stress incontinence surgery

Surgery for stress urinary incontinence (SUI) in women with previous interventions is often difficult and yields poor results. A total of 33 women with recurrent SUI underwent placement of a polytetrafluoroethylene (PTFE) sling after a mean of 1.5 (range, 1-3) unsuccessful operations. Preoperative bladder instability (BI) was ruled out in all cases. The patients' mean age was 54 (range, 34-79) years. In all, 64% had SUI and 36% had SUI and incontinence at rest. The Aldrige-Stoeckel technique is used with insertion of a 2 x 30 cm sling instead of fascia lata. Mean operating time was reduced in 40 minutes. After a mean follow-up period of 13 months, 72% of the patients achieved continence without retention (complete success). Altogether, 16 patients (48%) required self-catheterization after discharge, with the voiding imbalance lasting for more than 3 months in only 4 cases (12% of the total). Three patients underwent surgery for outlet obstruction. There were five abdominal wound infections but no vaginal wound infection. Two slings have since been removed (one partially), but none has eroded through the urethra. The PTFE sling is a reasonable option for this group of patients. Retention is usually self-limited, and most complications can be managed successfully.

Direct measurement of blood flow in the human bladder

PURPOSE

We evaluated blood flow in the human bladder.

MATERIALS AND METHODS

In 8 surgical cases a laser Doppler flow probe was placed in the bladder dome and anterior wall. In 10 endoscopic cases the flow probe was placed in the bladder trigone and lateral wall.

RESULTS

Bladder filling resulted in reduced mean blood flow in the dome and anterior wall. After prostatectomy blood flow decreased in the dome but not the anterior wall. During endoscopy bladder filling resulted in diminished blood flow.

CONCLUSIONS

Laser Doppler flowmetry can measure blood flow changes in the human bladder.

Urodynamic findings in children with spinal cord ischemia

PURPOSE

We identified urodynamic patterns of lower urinary tract dysfunction in children after anterior spinal artery injury.

MATERIALS AND METHODS

Between 1981 and 1993, 6 boys and 1 girl in whom ischemic spinal cord injuries developed after umbilical artery catheterization (4), cardiovascular surgery (2) and spontaneous bleeding from an arteriovenous fistula (1) were evaluated radiologically, neurologically and urodynamically.

RESULTS

Neurological assessment revealed a motor level from T8 to S1 in all 7 children, whereas only 3 had sensory denervation ranging from T8 to L4. Urodynamic studies demonstrated a mixed upper and lower motor neuron pattern in 3 patients, a lower motor neuron lesion only in 3 and a pure upper motor neuron deficit in 1. Treatment consisted of oxybutynin in 5 cases, Credé voiding in 1 and close observation in 1. All children are dry and kidney function has remained stable.

CONCLUSIONS

Spinal cord ischemia in children is a rare condition that can arise from a variety of causes, the most common of which are embolism from umbilical artery catheterization and surgical repair of a patent ductus arteriosus. The urodynamic patterns are variable but characteristically they can be upper or lower motor neuron in nature. Precise testing will lead to appropriate therapy to prevent upper urinary tract disease and minimize incontinence.

[Survey on information provided to hospitalized patients at a monographic center]

To assess the information of patients, eight interviewers surveyed simultaneously 103 of the 130 in patients of a monographic (Urology and Nephrology) Hospital. Answers to the 10 questions can be grouped in: a) Physician identification: 72% identified the visiting physician and 61% knew his/her name; b) Information about disease: 94% declared to be informed and thought information was adequate (92%) and understandable (83%); c) Information about procedures or interventions had been given to 82% and not given to 18% of them. 43% had been inquired their opinion about treatment; d) Information to relatives had been given to 97% of patients surveyed, although 16% couldn't recall who gave it. The level of information in our Center is similar to others reported, but two aspects could be improved: 1) identification of all members of the team and 2) increasing patient participation in decision making. The need of the knowledge by the patient of the Hospitals hierarchy should be defined.

[Bladder neck sclerosis after transurethral resection of the prostate. "Study Group of the Puigvert Foundation"]

We reviewed 623 patients who underwent trans-urethral resection of the prostate (TURP) and 18 (2.8%) developed bladder neck contracture (BNC), in most cases symptomatic. Sclerosis appeared between 2 and 100 months after TURP (mean 9 months, median 19 months). Most were small prostates at the time of resection, with a mean resected weight of 10.5 g (SD 5.9), although there were no statistically significant differences between patients with and without contracture. Patients have been followed for a mean of 44.5 months. Three patients were not operated: two were asymptomatic and another one died one month postoperatively due to unrelated causes. The overall success rate was 75% and cold knife incision of the bladder neck accounted for a 90% success rate. Cold knife incision provides good long term satisfaction in patients with post-operative BNC. The difficulties in the study of this complication are analyzed.

Significance of ureteral carcinoma in situ in specimens of cystectomy

In a retrospective review of 242 cystectomy specimens performed for bladder carcinoma, ureteral carcinoma in situ was found in 14 patients (5.7%), unilateral in 12 and bilateral in 2. Pathology of the bladder specimen was pT4 (6 cases), pT3 (3 cases), pT2 (1 case), pT1 (3 cases), and pT0 (1 case). In the cystectomy specimen and in previous biopsies, they all had grade 3 tumor, and 85% had bladder CIS. Two patients were lost during follow-up. Seven patients (58.4%) died of metastatic disease without evidence of upper tract recurrence (UTR). Their average survival was 15.8 months (range 4-60). Five patients (41.6%) are alive after an average follow-up of 33.6 months (range 18-72 months). In one case an UTR appeared 53 months after cystectomy. In patients with ureteral CIS and long-term survival, a careful follow-up is advisable. The incidence of UTR is increased in this subgroup (8% global and 20% of survivors) but mortality is due to progressive bladder disease.

Craniofacial anthropometric studies in Waardenburg syndrome type I

A set of 15 surface measurements taken directly from the craniofacial region were determined in 51 patients with Waardenburg syndrome type I (WSI). A roentgencephamometric analysis including 20 linear dimensions was also performed by the use of cephalograms of 28 patients. Pairs between patients and controls of the same sex and age were established for comparison. The head circumference, clivus length and facial depth were smaller in affected individuals. The patients also had narrow nose, marked hypoplasia of the nasal bone, short philtrum, and short and retropositioned maxilla. A discriminant analysis revealed that the inner intercanthal distance, philtrum length, lower facial height and nasal bone length were excellent discriminating parameters of WSI.

[The urologist's language: a survey on symptoms]

The definition of urologic symptoms varies depending on the source. Some symptoms are particularly vague and their clinical usefulness is doubtful. A survey was sent to 500 spanish urologists, asking about terminology and normality limits. There were 17 items, most of them as multiple choice questions, and all of them with the possibility of an open answer. The response rate, two months after the mailing was 12% (60 physicians). The variability of the answers was high for most of the items. In most questions over half of the respondents (between 50 and 70%, depending on the question) agreed, whereas the rest gave different answers. The free answers given were also different. This discrepancy affected all of the questions. The low response rate can be attributed to the scare tradition of this kind of survey in our country. The disparity in the definitions urges a unification of them, or at least that authors explain what they understand when they mention any symptom or syndrome.

Wound infection rates in clean surgery: a potentially misleading risk classification

OBJECTIVES

To evaluate the incidence of wound infection in inguinal hernioplasties, incisional hernioplasties, splenectomies, and splenectomies performed in patients with hepatosplenic schistosomiasis, and to examine the relationship of surgical wound infection to antibiotic use, patient age, length of stay in the hospital prior to surgery, and the duration of the operation.

DESIGN

Retrospective surveillance study.

RESULTS

One thousand five hundred forty-two clean operations were analyzed. Comparing response (wound infection) and explanatory variables (age, length of hospital stay, duration of surgery, antibiotics, and surgery type), we found that age, use of antibiotics, and type of surgery were statistically significant, while length of hospital stay and duration of surgery were not significant.

CONCLUSIONS

From these results, we can predict that the probability of wound infection in surgical patients considering these significant variables is lower for patients ages 14 to 30 years and higher for patients ages 31 to 60 years and lower for patients with prophylactic antibiotic use (up to 72 hours of use) and higher for patients with prolonged use (more than 72 hours); and lower for patients undergoing inguinal heria, followed in ascending order by nonschistosomotic patients undergoing splenectomy in schistosomotic patients.