Transurethral balloon dilation of the external urinary sphincter: effectiveness in spinal cord-injured men with detrusor-external urethral sphincter dyssynergia

The authors investigated balloon dilation as a minimally invasive alternative to transurethral external sphincterotomy for the treatment of detrusor-external urethral sphincter dyssynergia (DESD). Seventeen spinal cord-injured men with voiding pressures greater than 60 cm H2O underwent balloon dilation of the external sphincter to 90 F at 4 atm of pressure for 10 minutes. The mean voiding pressures before and 12 months after dilation were 83 cm H2O +/- 35 and 37 cm H2O +/- 15, respectively (P = .008). There was a significant decrease in residual urine volume, from 163 mL +/- 162 to 68 mL +/- 59 (P = .05), whereas bladder capacity remained relatively unchanged at 253 mL +/- 181 and 230 mL +/- 97 (P = .30). Complications included one case of postoperative bleeding necessitating transfusion, two treatment failures, and one bulbous urethral stricture. Fourteen of the 17 patients (82%) now void without the aid of an indwelling catheter or alternative therapy. Balloon dilation has no detrimental effect on erectile function and may improve fertility.     

Anal sphincter stretch: a technique to overcome detrusor-sphincter dyssynergia

Intermittent catheterization has become a well-accepted method of management of the neurogenic bladder following spinal cord injury. Frequently, the presence of detrusor-sphincter dyssynergia interferes with the attainment of acceptable residual urine volumes in patients with upper-motor-neuron bladders. We have recently reported success in overcoming the problems of dyssynergia in some patients utilizing a technique called anal sphincter stretch in which relaxation of the external anal and urethral sphincters is produced by sustained distention of the anal sphincter. This has lessened the need for other measures that usually produce incontinence and has met with good patient acceptance. An update on the results of using this technique is presented. Although we have previously encountered quadriplegics who might have benefited from sphincter stretch, the lack of hand intrinsic muscle function required for the patient to perform it independently has precluded its use. We herein present a device that circumvents inadequate hand function, and which has enabled four C-7 quadriplegics to achieve satisfactory bladder emptying.     

An urodynamic study on neobladder function

OBJECTIVE: To analyze the urodynamic characteristics of neobladders, we conducted a pressure-flow study in patients with orthotopic urinary reservoirs. PATIENTS AND METHODS: From 1986 to 1996, 90 patients underwent bladder replacement following cystectomy, using a right colonic, ileocolic, ileal, or sigmoid colonic segment. The subjects were 38 patients (31 men and 7 women) with stable urination and no evidence of cancer recurrence, urethral stricture, urinary tract infection or vesicoureteral reflux. Their mean age was 60.5 years, with a range of 38 to 77 years. Information on neobladder function, such as desire to void, force of micturition, urinary incontinence and other complaints, was obtained by questionnaire. A pressure-flow study was performed in all patients 3 months to 103 months postoperatively to evaluate total reservoir pressure, abdominal pressure and subtracted reservoir pressure during filling and voiding phases. RESULTS: Ten of 38 patients (26.3%) were dissatisfied with their neobladder function, due to weakness of urinary sensation, loss of urinary force and enuresis. In 6 of the 7 patients with enuresis, the urinary reservoir had been created by Heineke-Mikulicz's procedure of detubularization; 4 of these patients had a high degree (over 40 cmH2O) of phasic contraction during the filling phase. In only 2 of the 38 patients, a pressure-flow study showed an almost same pattern as that obtained with a normal urinary bladder. Twelve patients had increased electromyogram of the external urethral sphincter during the voiding phase, while half of the 38 patients showed a flat electromyogram during both the filling and voiding phases. Thus, 31 of 38 patients revealed a sphincter dyssynergia pattern. Mean total reservoir pressure at maximum cystometric capacity was 65.5 +/- 42.1, 48.4 +/- 19.0, 66.0 +/- 61.0 and 107.0 +/- 43.3 cmH2O in ileal, ileocecal, right colonic and sigmoid neobladders, respectively. The value for sigmoid neobladder was statistically different from that for ileocecal neobladder (p < 0.05). Mean total reservoir pressure at maximal flow was 73.1 +/- 42.4, 56.4 +/- 22.6, 88.9 +/- 69.4 and 94.0 +/- 31.8 cmH2O in ileal, ileocecal, right colonic and sigmoid neobladders, respectively. There were no statistically significant differences among these values. The ratio of subtracted reservoir pressure to total reservoir pressure was lower at maximal flow than at onset. Subtracted reservoir pressure may contribute to total reservoir pressure to a greater extent in sigmoid neobladders than in other types of neobladder. CONCLUSIONS: 1. Enuresis may have various causes such as external sphincter dysfunction and involuntary contraction of the reservoir. 2. Urine is evacuated not only by abdominal pressure but also by subtracted reservoir pressure in neobladders. 3. Sphincter dyssynergia due to absence of the detrusor muscle may be one cause of dysuria.     

Urological symptomatology in patients with reflex sympathetic dystrophy

PURPOSE: We determined the effect of reflex sympathetic dystrophy on lower urinary tract function. MATERIALS AND METHODS: A total of 20 consecutive patients (16 women and 4 men) with neurologically verified reflex sympathetic dystrophy was referred for voiding symptoms, including urgency, frequency, incontinence and urinary retention. No patient had had voiding symptoms before the initial trauma that induced reflex sympathetic dystrophy. Evaluation included medical history, physical examination, video urodynamic testing and cystoscopy. RESULTS: Mean patient age was 43.4 +/- 10.2 years (range 28 to 58) and mean duration of urological symptoms was 4.9 +/- 3.6 years (range 1 to 14). Urodynamic study demonstrated a mean cystometric bladder capacity of 417 +/- 182 ml. (range 120 to 700). The urodynamic diagnoses included detrusor hyperreflexia in 8 patients, detrusor areflexia in 8, sensory urgency in 3 and detrusor hyperreflexia with detrusor-external sphincter dyssynergia in 1. In 4 women genuine stress urinary incontinence was also documented urodynamically. CONCLUSIONS: Reflex sympathetic dystrophy may have a profound effect on detrusor and sphincter function.     

Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitute

PURPOSE: The effect of cystoprostatectomy with orthotopic substitution on membranous urethral sensation and subsequent urinary continence is unknown. We determined the sensory threshold for electrical stimulation of the membranous urethra and correlated it with continence, nerve sparing surgical technique and potency. MATERIALS AND METHODS: The sensory threshold was measured in a control group of 35 men before radical prostatectomy or cystoprostatectomy and in 47 men after cystoprostatectomy and ileal bladder substitution. RESULTS: The sensory threshold of the membranous urethra was 9+/-2 in the control group compared to 27+/-11 mA. in the postoperative group (p<0.001). Patients with daytime continence had a threshold of 24+/-9 compared to 39+/-10 mA. in incontinent patients (p<0.001). We were unable to show any correlation between the sensory threshold in patients with (25+/-10 mA.) and without (31+/-11 mA.) attempted nerve sparing surgery (p = 0.1) nor between potent (25+/-12 mA.) and impotent (27+/-11 mA.) patients (p = 0.4). CONCLUSIONS: Sensitivity in the membranous urethra decreased in patients after cystoprostatectomy and ileal bladder substitution. Urethral sensitivity in the sphincter area was better in continent than incontinent patients. Since we were unable to find any correlation between the sensory threshold and nerve sparing surgery or potency, it may be assumed that at least part of the sensory fibers to the membranous urethra pass through the pudendal nerve and/or the intrapelvic extrapudendal nerve fibers.     

Treatment of external urethral sphincter hypertonicity by pudendal nerve block using phenol solution in patients with spinal cord injury

We report our experience utilizing the technique of phenol block of the pudendal nerve in the treatment of voiding dysfunction due to hypertonicity of the external urethral sphincter. We have performed 13 pudendal nerve blocks using a 7% phenol solution in seven patients with spinal cord injury who could not obtain relaxation of the external urethral sphincter with a large postvoid urine residual (150 ml to 600 ml) despite large doses of antispasticity drugs and intermittent catheterisations over three weeks. These drugs were discontinued at least 48 hours before this procedure. The efficacy of the pudendal nerve block could also be tested by the ease of facilitating micturition during or just after the block and measuring the amount of postvoid residual urine and intravesical leak pressure. A pudendal nerve block was produced by injecting a 7% phenol solution medial to the ischial tuberosity having specifically localized the nerve by electrical stimulation. This procedure improved the voiding pattern dramatically, leading to a full stream of urine and a remarkable decrease of postvoid residual volume and intravesical leak pressure. The mean difference of the postvoid residual volume and the intravesical leak pressure before and after pudendal nerve block was 255.7 ml and 57.5 cmH2O, respectively. We conclude that pudendal nerve block with a phenol solution as a treatment of external urethral sphincter hypertonicity was effective, easy to perform, and had no complication. This treatment should be considered as a possible alternative to more invasive surgical procedures.     

Clinical features of transurethral anterior sphincterotomy and urological management of patients with cervical spinal cord injury

BACKGROUND: The ideal urological management for the patients with cervical spinal cord injury (CSCI) is to obtain catheter free urination and to prevent urinary tract complications. We have evaluated cases that had undergone transurethral anterior sphincterotomy from the view-point of the operative indications and the efficacy. METHODS: We carried out sphincterotomy 166 times on 133 male patients with CSCI in our Center. Before the operations were performed, all patients suffered from urinary incontinence, and they were unable to catheterize themselves for low level activity of daily life. Before and after the operation, their detrusor functions with sphincter reactions were assessed by urodynamic study. In principle we have followed up these cases by cystogram combined with cystometry, cystogram and excretory-pyelography or abdominal ultrasonography. RESULTS: In post-operative evaluations, more than 80% of cases attained hypotonic detrusor contractions and residual urine was significantly decreased. In long term follow-up, 96% of patients had obtained catheter free urination and about 85% of patients had no urinary tract complications, such as bladder deformity, vesicoureteral reflux, or hydronephrosis, with the exception of common unavoidable urinary infections. About 20% of cases had to be re-operated upon, and some cases showed hypertonic detrusor contractions or detrusor-sphincter-dyssynnergia during follow-up. CONCLUSION: The operative indications of sphincterotomy should be decided when the CSCI patients is unable to perform self-catheterization, and when due to the dysfunction of the urethral sphincter, these patients suffered from voiding difficulties or autonomic dysreflexia, or when the urinary tract complications might occur. In the majority of cases the aims of the sphincterotomy were achieved but some cases underwent another operation or had recurrent dysfunction of the urethral sphincter, indicating the need for careful follow-up.     

A comparative study on coronary angiography and exercise ECG testing

42 patients with chronic urinary retention caused by BPH were treated by means of Mesh-like tubular stent placing from August 1993 to August 1994. The mesh-like tubular stent was made of nickel titanium alloy in sizes of 2.0 x 1.5 cm, 2.5 x 1.5 cm, 3.0 x 1.5 cm respectively. Under direct vision the stent was placed with the deployment tool. The desirable position of the stent is 0.3-0.5 cm proximal to the internal urethral orifice, 0.5 cm distal to the verumontanum. In 38 patients followed up for 1-6 months, 34 were succesful with an effective rate of 80%. IPSS, PUFR, RUV after 1, 3, 6 months of placement were 8.5 +/- 4.4, 6.8 +/- 3.5, 7.1 +/- 5.2; 12.5 +/- 6.0 ml/s, 14.0 +/- 5.2 ml/s, 14.4 +/- 8.1 ml/s; 43 +/- 11.5 ml, 47.4 +/- 13.3 ml, 44.5 +/- 15.7 ml respectively. Four stents were taken away transurethrally in the unsuccessful cases. The results indicat that there are no serious complications except for shorttime hematuria, fever, and bladder irritation. The success depends chiefly upon exactly meassuring the length of prostatic urethra, selecting the rational size of the stent, and correctly placing the stent.     

HLA-DRB1 alleles and beta 2 glycoprotein I-dependent anticardiolipin antibodies in Japanese patients with systemic lupus erythematosus

PURPOSE: This study was designed to evaluate the anatomic and functional consequences of lateral internal sphincterotomy in patients who developed anal incontinence and in matched controls. METHODS: The study includes 13 patients with anal incontinence after lateral internal sphincterotomy and 13 controls who underwent the same operation and were continent and satisfied with the results of the procedure. Patients underwent clinical evaluation, anorectal manometry, pudendal nerve terminal motor latency testing, and endoanal ultrasonography. RESULTS: Sphincterotomies were longer in incontinent patients (75 vs. 57 percent), but the resting pressure and length of the high-pressure zone were not different between groups. Surprisingly, maximum voluntary contraction was higher in incontinent patients than in continent controls (136 vs. 100 mmHg). Rectal sensation and pudendal nerve terminal motor latency were similar in both groups. The defect in the internal sphincter was wider in incontinent patients than in continent controls (17.3 vs. 14.4 mm), but these differences were not statistically significant. The thickness of the internal sphincter measured by endoanal ultrasound was identical in both groups, but the external sphincter was thinner in incontinent patients both at the site of the sphincterotomy (6.8 vs. 8.1 mm) and in the posterior midline (7.1 vs. 8.6 mm). CONCLUSIONS: Anal incontinence after lateral internal sphincterotomy is directly related to the length of the sphincterotomy. Whether secondary to preoperative sphincter abnormality or the result of lateral internal sphincterotomy, the external sphincter is thinner in incontinent patients than in continent controls.     

Functional reinnervation in patients with a diagnosis of lower motor neuron neurogenic bladder: prognostic and therapeutic considerations

OBJECTIVE: To evaluate bladder and urethral sphincter reinnervation mechanisms during long-term follow-up in patients with lower motor neuron neurogenic bladder following neurological surgical injury. METHODS: A urodynamic study was conducted in 30 patients (21 male and 9 female; mean age 53.4 years) with lower motor neuron neurogenic bladder dysfunction arising from neurological injury sustained during surgery. The protocol included cystometry and periurethral electromyography (EMG) at 3, 6, 9, 12 months and once a year for 7 years, and videocystography at 3, 12 months and once a year for 7 years. Functional parasympathetic (detrusor) reinnervation criteria were cystometric. Functional sympathetic (bladder neck) reinnervation criteria were cystographic. Functional pudendal (periurethral sphincter) reinnervation criteria were electromyographic (increase of polyphasic and long amplitude and/or long time potentials). RESULTS: Detrusor reinnervation was demonstrated in 6 male patients (20%) with an average period of 44.6 months. Pudendal reinnervation was demonstrated in 17 patients (77.2%) with an average period of 17.6 months. EMG potentials were polyphasic in 17 cases and long amplitude/long time potentials in 3 cases. Sympathetic reinnervation was demonstrated in one patient (16.6%) at 60 months. CONCLUSIONS: Functional pudendal reinnervation of the periurethral sphincter was more frequent and was demonstrated earlier than reinnervation in vegetative elements (parasympathetic and sympathetic). Parasympathetic reinnervation had long-term therapeutic implications. Ongoing urodynamic assessment in patients with lower motor neuron neurogenic bladder following abdominoperineal resection or intervertebral disc prolapse surgery is warranted. Sympathetic reinnervation was scanty and was demonstrated later in relation to distal postganglionic fibers.     

Intranasal steroids and septum perforation--an overlooked complication? A description of the course of events and a discussion of the causes

One of urodynamic diagnostic methods is visualisation of the bladder neck opening which enables seeing the difference between internal and external urethral sphincter disfunction. Micturition video cysto-urethrography with X-rays makes possible to carry on such examinations, but it requires catheterisation which makes the method invasive. My purpose is to replace this examination by dynamic functional evaluation of the internal urethral sphincter during transrectal ultrasonography. During 10 routine transrectal ultrasound examinations of the prostate, patients were asked to urinate. During examination changes in configuration of the bladder neck and prostatic urethra were observed. Two patients could not urinate in horizontal position. In the rest of the patients very clear pictures showing changes in the shape and dimensions of the urethra during urination, were achieved. They were much more clear in comparison with X-ray video cystourethrography. Transrectal sonography is a perfect technique of the visualisation of the bladder neck and prostatic urethra during urination. The suggested method should be included into the urodynamic examinations.     

Endoscopic treatment of vesicoureteral reflux in patients with myelodysplasia

PURPOSE: We assessed the usefulness of and indications for endoscopic treatment of vesicoureteral reflux in myelodysplasia patients. MATERIALS AND METHODS: A total of 26 patients treated with intermittent catheterization was divided into 11 (16 ureters) with and 15 without vesicoureteral reflux. In 9 patients (13 ureters) endoscopic correction was performed with 3% atelo-collagen and without anesthesia at the outpatient clinic. In each ureter we obtained the sum of scores for 4 risk factors for upper urinary tract deterioration: bladder compliance less than 10 ml./cm. water, grade 2 to 3 bladder deformity, detrusor-sphincter dyssynergia and urethral closure pressure 50 cm. water or greater. RESULTS: No reflux was demonstrated immediately after the initial collagen injection but cystography 3 to 6 months later showed recurrent reflux in 5 ureters (38%). Repeat injection cured the reflux, with results persisting for an average of 17 months. Mean risk factor score for patients without vesicoureteral reflux was significantly lower than that for patients with reflux. In patients treated with intermittent catheterization and anticholinergic agents the mean score for ureters with an increased or unchanged reflux grade was significantly greater than for those with a decreased grade. CONCLUSIONS: Endoscopic treatment of reflux appears to be safe and useful in patients with myelodysplasia. The treatment is preferable in those with high risk factor scores due to the possibility of increased reflux grade in such patients.     

Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy

OBJECTIVE: This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy. METHODS: Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months. RESULTS: Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up. CONCLUSIONS: Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.     

Mayo Clinic long-term analysis of the functional durability of the AMS 800 artificial urinary sphincter: a review of 323 cases

PURPOSE: We determine the long-term durability of the AMS 800* artificial urinary sphincter in the correction of severe urinary incontinence, and evaluate mechanical versus nonmechanical failure and reoperation rates before (1983 to 1987) and after (1988 to present) the introduction of the narrow backing occlusive cuff design. MATERIALS AND METHODS: From January 1983 to October 1994 more than 400 patients received an AMS 800 artificial urinary sphincter placed by 1 surgeon and 323, mean age 60.4 years, met study requirements for review. Mean followup was 68.8 months (range 18 to 153). Only patients with a minimum of 18 months of followup were included in the study. Of the 313 men and 10 women in the study group sphincters were placed at the urethra in 272 and at the bladder neck in 51. All patients were followed from surgery to the date of sphincter failure. Etiology of the failures was recorded and divided into mechanical versus nonmechanical sphincters placed before and after the introduction of the narrow backing cuff. RESULTS: Overall, 58 of the 139 patients (42%) in the pre-narrow backing cuff group versus 31 of the 184 (17%) in the narrow backing cuff group required a first reoperation. Mechanical failure occurred in 29 cases (21%) with the pre-narrow backing and 14 (7.6%) with the narrow backing cuff. Nonmechanical failure developed in 24 cases (17%) with the pre-narrow backing and 17 (9%) with the narrow backing cuff. Ultimately 437 operations were required in the 323 patients, of whom 234 (72%) required no further surgical intervention at a mean followup of 68.8 months. CONCLUSIONS: Technological advances in the design and construction of the AMS 800 have dramatically decreased the reoperation and failure rates. These advances and improved surgical techniques provide an excellent long-term solution and increased continence in correctly selected patients with urinary incontinence.     

The acute and 24-hour modifications to the atrial natriuretic factor in patients who have undergone mitral valvuloplasty. The hemodynamic and echocardiographic correlations

BACKGROUND: The recent introduction of percutaneous transvenous mitral valvuloplasty (PTMV) for the treatment of mitral stenosis (MS) has provided a unique human model for the study of short-term changes in ANF secretion before and after a reduction in left atrial pressure. This study was designed to investigate the effect of a short-term reduction in left atrial pressure and volume, as determined by echocardiographic study, on ANF and other neurohumoral factor plasma levels (renin and aldosterone). MATERIALS AND METHODS: 10 patients in III FC NYHA, with normal sinus rhythm and MS underwent PTMV. Hemodynamic parameters were measured immediately before and after (20-30 minutes) PTMV. Plasma levels of ANF, aldosterone and plasma renin activity (PRA) were obtained before (24 h) and after (2 h and 24 h) valvuloplasty; echocardiographic left atrial size before (24 h) and 24 h after PTMV. RESULTS: Immediately after PTMV mean left atrial (LA) pressure decreased from 22.3 +/- 6.8 mmHg to 10.0 +/- 2.4 mmHg (p < 0.01); mitral valve area (MVA) increased from 0.99 +/- 0.28 cm2 to 2.17 +/- 0.26 cm2 (p < 0.01). 24 hours after PTMV on echocardiography, LA systolic volume decreased from 59.5 +/- 16.9 cm3 to 42.3 +/- 8.3 cm3 (p < 0.01), LA diastolic volume from 82.6 +/- 15.8 cm3 to 66.5 +/- 12.6 cm3 (p < 0.01), and LA diameter from 48.1 +/- 7.5 mm to 39.2 +/- 4.4 mm (p < 0.01). ANF plasma levels before PTMV were 64.0 +/- 36.9 fmol/ml; 2 and 24 hours after PTMV they fell to 34.2 +/- 21.6 fmol/ml (p < 0.01) and to 20.3 +/- 21.0 fmol/ml (p < 0.01), respectively. PRA values were 15.7 +/- 13.2 ng/ml/h before PTMV; 2 and 24 hours after PTMV they increased to 17.5 +/- 23.2 ng/ml/h (NS) and to 22.3 +/- 16.8 ng/ml/h (p < 0.01). The aldosterone plasma levels were 43.2 +/- 27.9 ng/dl before PTMV and 47.3 +/- 35.8 ng/dl (NS) and 45.3 +/- 28.0 ng/dl (NS) 2 and 24 hours after PTMV. CONCLUSIONS: These results indicate that LA "de-stretching" due to the MVA increase and LA pressure decrease, leads to an abrupt reduction of ANF secretion. According to other studies, PRA increases immediately after PTMV, with a further increase 24 hours after PTMV.     

Stress urinary incontinence in women caused by severe sphincter hypotonia. Goebbel-Stoeckel intervention as alternative to artificial sphincter. Apropos of 26 cases treated between January 1985 and January 1994

Stress urinary incontinence with low urethral closure pressure and urethral mobility is often treated by artificial urinary sphincter. Our retrospective report in 19 patients evaluates the sling procedure as an alternative to the artificial urinary sphincter (7 patients). All patients had a preoperative clinical and urodynamic evaluation. 13 patients were continent (68.4%) in the sling procedure group and 5 in the sphincter group. Continence remained stable with a mean follow-up of 77 months (range: 39-110 months). 2 patients had urgency and none had dysuria. The sling procedure gave us the same results as sphincter with less morbidity.     

Biochemical changes in denervated muscle identified by magnetic resonance spectroscopy

The significance of the ASIA (American Spinal Injury Association) scores and SSEP (somatosensory evoked potentials) recordings in predicting the recovery of bladder function was evaluated in 70 patients with acute, traumatic spinal cord injury (SCI). The patients were examined following admission to the rehabilitation centre (mean 10 days post-trauma) both clinically by the ASIA scores and electrophysiologically by tibial and pudendal SSEP recordings. The results of the initial examinations were related to the degree of recovery of bladder function of the patients assessed by urodynamic examination at the end of the rehabilitation programme (at least 6 months post-trauma). The recovery of somatic nerve function (external urethral sphincter function) involved in bladder function was correlated to both the initial ASIA scores and SSEP recordings (Spearman correlation, P < 0.001). The latter parameters, however, were not related to the outcome of autonomic nerve function (eg detrusor vesicae function) (Spearman correlation, P = 0.1). Therefore, the initial clinical and electrophysiological examinations are of value in assessment of the degree to which the patient will recover somatic nervous control of bladder function. However, these examinations are not indicative of urodynamic impairment. Therefore, urodynamic examination should be mandatory for the diagnostic assessment and therapeutical approach of bladder dysfunction in patients with acute SCI.     

Acute and delayed hormonal changes in mitral stenosis treated by balloon valvulotomy

The role of left atrial and aortic pressures on the secretion of the main hormones controlling blood volume is still subject to debate in humans. Because of increased mean left atrial pressure and decreased mean aortic pressure produced by balloon inflation in patients with mitral stenosis treated with balloon valvulotomy, the hormonal changes occurring acutely (group II of patients) were measured. The same studies (group I patients) were also performed 48 hours after this treatment, a period at which left atrial pressure permanently diminished. Inflation of the balloon resulted in a decrease in plasma renin activity and increases in plasma atrial natriuretic factor (ANF) and plasma arginine vasopressin (AVP). Forty-eight hours after balloon valvulotomy, which had produced a decrease in left atrial pressure, plasma ANF was lower (58.9 +/- 7.9 vs 95.3 +/- 11.9 pg/ml; p < 0.001), and plasma renin activity (2,575 +/- 533 vs 960 +/- 113 pg/ml/hour; p < 0.01), plasma angiotensin II (25.0 +/- 4.1 vs 9.3 +/- 1.3 pg/ml; p < 0.001) and plasma aldosterone (181.7 +/- 36.7 vs 139.9 +/- 19.8 pg/ml; p < 0.05) were higher than their respective control levels 24 hours before treatment of the stenosis. In contrast, plasma AVP (3.7 +/- 0.25 vs 4.4 +/- 0.31 pg/ml; p = 0.001) diminished moderately along with plasma osmolality (282.4 +/- 0.1 vs 286.2 +/- 0.6 mOsm/kg; p < 0.001). Urinary sodium excretion was also examined before and after balloon valvulotomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of posterior teeth replacement on temporomandibular joint sounds: a preliminary report

Previous reports have shown the prevalence of jaw clicking to be significantly higher in a population with missing posterior teeth compared with an dentulous population. This study presents a 2- to 5-year assessment of the effects of posterior teeth replacement on the amplitude of jaw clicking in subjects who were asymptomatic in all respects except jaw clicking. Patients requiring removable partial dentures (RPDs) were clinically and anamnestically examined and temporomandibular joint (TMJ) sounds were recorded using a modified stethoscope attached to an adjustable headgear. Amplified signals were displayed on a strip chart recorder. The amplitude of TMJ sounds at preinsertion of RPDs were 27.5 +/- 17.7 dB at opening, and 11.1 +/- 12.7 dB at closing. Similar values after prosthesis insertion were 15.8 +/- 17.0 dB and 7.4 +/- 7.5 dB, respectively. Paired t test analyses showed significant differences in the amplitude of sound for opening and closing before inserting the prosthesis (p = 0.003) and for opening before and after treatment (p = 0.014). Following replacement of posterior teeth, the clicking amplitude decreased in 68% of recordings, remained unchanged in 11%, and increased in 21%.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.