Bladder washout and stone formation in paediatric enterocystoplasty

OBJECTIVE

To review the incidence of stone formation in our patients with enterocystoplasty to determine the effect of regular bladder washout.

METHODS

From 1988 to 1995, a prospective cohort of 30 children underwent enteroplasty with continent diversion. Over the same period, a consecutive group of 30 children had an augmentation alone. All were instructed to wash out their bladder on a weekly basis with sterile water. The frequency of the washouts increased if there were problems with increasing mucus production. Their incidence of stone formation has been compared to a similar group of 30 children performing clean intermittent self catheterisation (CISC) on their native bladders.

RESULTS

Five (17%) children with continent diversions formed bladder stones (mean time to formation 35 months, range 13-59 months) were compared with 2 (7%) of children with augmentation. No child performing CISC alone formed stones.

CONCLUSIONS

A regime of regular bladder washout in children with enterocystoplasty did not significantly reduce the incidence of stone formation when compared to previously published data.

The effect of diclofenac (voltarol) and pethidine on ureteric peristalsis and the isotope renogram

Diclofenac (a non-steroidal anti-inflammatory drug) and pethidine (a synthetic opiate) are the two analgesics most commonly used to relieve the pain of ureteric colic. Fast frame renography is a non-invasive means of imaging ureteric peristalsis and renal drainage. The aim of this study was to determine the effects of each of these drugs on the drainage pattern of the upper tracts. Twelve normal male volunteers were studied. All underwent a standard fast frame renogram using 75 MBq of technetium-99m-mercaptoacetyltriglycine, and were then administered either 100 mg pethidine or 75 mg diclofenac by intramuscular injection. Fast frame renography was then repeated. Peristalsis was determined from the condensed image of each ureter and the renogram curves were analysed to obtain standard parameters and deconvolution analysis. Diclofenac caused a profound disruption to both ureteric peristalsis and the renogram curve. This effect was not seen after the administration of pethidine. Deconvolution analysis suggests the effects of diclofenac are mediated via a direct effect on drainage rather than by any alteration of blood flow to the kidney. This study suggests that pethidine is the analgesic of choice prior to renography and that inferences about alterations of drainage in the presence of diclofenac should be interpreted with care.

Resource implications of outpatient referrals to a general urological service

The effects of new outpatient referrals on the dynamics of global provision in a surgical service has not previously been defined. Because of managerial pressure to reduce the time interval between general practitioner referral and first specialist assessment, many services are now faced with additional outpatient loads without any clear idea of the effect that this additional burden will have on overall practice. In an attempt to define the logistic implications of a new outpatient load, 293 patients, referred from primary care to a general urological service, were followed for a further two interactions with the secondary care team. 'One-stop' visits with in-clinic investigation and an active discharge policy were employed to assist with efficient patient management. Of the original patients, 28% required investigations not available in the clinic, with cost and logistic implications for support services. In all, 32% of the patients needed further follow-up appointments, despite the active discharge policy. This necessitated 95 people being seen in additional clinic time. Of the patients referred, 37% needed inpatient treatment; 46% being day case procedures, the remainder constituting a variable case mix. This work necessitated 7.1 operating sessions and an additional 75 inpatient bed days for every 100 new patients referred. A model for determining the resource requirements for a surgical outpatient load is proposed.

Identification of patients requiring out-patient follow-up after transurethral prostatectomy: is there a role for nurse-led screening of post-operative outcomes by telephone?

OBJECTIVE

To determine the most efficient method to follow patients after transurethral prostatectomy (TURP) such that only those patients suffering significant post-operative problems are reviewed.

PATIENTS AND METHODS

The study comprised two parts: (1) a retrospective review of the case notes of 100 consecutive patients who underwent TURP under one consultant to determine whether any factors could be identified pre- or post-operatively by which those patients most likely to require clinic review could be selected and; (2) a prospective review of the succeeding 100 patients undergoing TURP, using a telephone 'screening' call made by the urological research nurse 3 months after the operation. Patients who requested follow-up and those patients with malignancy or admitted in high-pressure chronic retention were reviewed in the out-patient department.

RESULTS

In the first part, 17 patients (17%) required an out-patient review for malignancy. Only nine patients (11%) with benign histology required further treatment after TURP; this subgroup could not be identified on the basis of their pre- or post-operative symptoms. In the second part, 23 patients were not reviewed by telephone; 14 had carcinoma of the prostate, eight had no telephone and one could not be contacted after seven attempts. Of the remaining 77 contacted by phone, 61 (79%) declined further clinic review and 16 (21%) requested follow-up for persistent problems. A mean of two calls was made per patient and the mean duration of each call was 6.3 min.

CONCLUSIONS

Based on pre- or post-operative symptoms at the time of discharge, there is no reliable method of identifying those patients who have a poor result after TURP. Telephone screening of patients at 3 months identified successfully those patients who required an out-patient review and enabled resources to be targeted towards this difficult group of patients.

Recurrent pelvic endometriosis and bilateral ureteric obstruction associated with hormone replacement therapy

Images

EMLA cream anaesthesia for frenuloplasty

OBJECTIVE

To evaluate the use of a eutectic mixture of local anaesthetics (EMLA) cream as the sole anaesthetic for frenuloplasty.

PATIENTS AND METHODS

Fifteen patients (mean age 25.6 years, range 19-41) were given topical EMLA cream 30 min before frenuloplasty; a Tegaderm dressing was applied to keep the anaesthetic in place. The level of anaesthesia was assessed on arrival in theatre using pin-prick testing and the patients were asked to grade their level of pain during the procedure using a visual analogue scale. If the level of anaesthesia was inadequate for the operation to be performed, then supplementary infiltrative anaesthesia was administered.

RESULTS

Fourteen patients had pain scores of zero and were fully anaesthetized during the procedure. One patient's Tegaderm dressing was displaced soon after application and he was inadequately anaesthetized on testing, had a pain score of 4 and required infiltrative lignocaine before proceeding with frenuloplasty.

CONCLUSIONS

EMLA cream is a well-tolerated and reliable anaesthetic for frenuloplasty. Using a condom to keep the cream in place would reduce the small failure rate associated with the displacement of the Tegaderm dressing.