Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder

OBJECTIVES: Although the urologic outcomes of augmentation cystoplasty for neurogenic bladder dysfunction are well known, additional information about the patient perspective is needed. The aim of this study was to assess patient perspective using a standardized questionnaire. METHODS: Fifty-nine patients, who had undergone augmentation enterocystoplasty as part of reconstruction mainly to correct hyperactive bladders and incontinence, were subjected to a questionnaire after a median of 76.1 postoperative months. The questionnaire addressed medications, catheterization, incontinence, bowel dysfunction, and satisfaction with urinary tract management. The urologic outcomes regarding upper and lower tract changes, complications, and reinterventions were documented as well. RESULTS: The patients experienced a significant increase in bladder capacity and decrease in pressure at capacity (P < 0.0001). Normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Twenty-four patients (40.6%) had one or more complications, with 21 requiring reinterventions. Twenty-five percent of patients required the reintervention within the first 25 months, and the median time to reintervention was almost 10 years. Thirty-five patients took medications such as anticholinergics, antidiarrheals, or antibiotics. Fifty-six patients were treated with clean intermittent catheterization (CIC) at a mean interval of 4.6 hours. Seven patients had some difficulty with CIC. Thirty-nine patients (67%) were dry, and 17 had mild and 3 severe incontinence. Eleven patients (18.6%) reported bowel dysfunction, although 7 had it preoperatively. Almost all patients were very satisfied with their urologic management. CONCLUSIONS: The high degree of patient satisfaction attests to the value of the procedure. The complication and reintervention rates underscore the importance of long-term follow-up.     

Castanospermine, an oligosaccharide processing inhibitor, reduces membrane expression of adhesion molecules and prolongs heart allograft survival in rats

The clinical characteristics and natural history of 55 cases with antenatally diagnosed fetal uropathy were investigated. Percutaneous aspiration of the fetal pelvic or vesical urine was performed to decompress progressive unilateral hydronephrosis in 2 cases and to evaluate renal function in another 2 cases of bilateral hydronephrosis. As the postnatal diagnosis, upper urinary tract dilatation (hydronephrosis or hydronephroureter, 33 cases) and renal dysplasia (15 cases) made up 87% of all cases. A combination of hydronephrosis in one kidney and renal dysplasia in the other was also found in another 2 cases. Among 35 cases with upper urinary tract dilatation, 27 cases demonstrated pelviureteric junction stenosis and surgical intervention was necessary in 15 cases. In 17 cases with renal dysplasia, spontaneous regression was observed in only 3 cases and surgical intervention by means of percutaneous nephrostomy and nephrectomy was performed in 4 and 6 cases, respectively.     

Clean intermittent catheterization for home management in children with myelomeningocele

Sixty-two children with myelomeningocele and neurogenic bladders have been managed with clean intermittent catheterization (CIC) at home for periods of 6 to 42 months. Abnormal upper urinary tracts improved or stabilized in 83 per cent of the children. There was no renal deterioration in children who began with normal upper tracts while on CIC. Bacteruria was common, but clinically not a problem, unless ureterovesical reflux was present. Urinary control was improved in 66 per cent of the children. CIC is an effective and safe method to regularly empty the urinary bladder and is an alternative to supravesical urinary diversion in many children with neurogenic bladders.     

A clinical isolate of Candida palmioleophila formerly identified as Torulopsis candida

To reassess the impact of renal ultrasonography on the care of children with first febrile urinary tract infection (UTI) we conducted a computer search and review of medical records of (1) all children who were admitted to our hospital with first febrile urinary tract infection and underwent renal ultrasonography during a 25-month period beginning February 1, 1995, (2) all children diagnosed by ultrasound to have hydronephrosis during the same time period. Of a total of 124 patients with UTI, renal ultrasound appeared normal or showed evidence of acute pyelonephritis in 105 (84.7%), and in another nine (7.2%) it showed only minor findings. In 10 children (8.1%) ultrasound showed hydronephrosis and/or hydroureter. In eight of the latter 10, voiding cystourethrography showed vesicoureteral reflux; in one, posterior urethral valves; and in one, who had a unilateral nonobstructed dilatated system, cystography appeared normal. Except for the last patient, who was given prophylactic antibiotics and continued to have urinary tract infections, in no other case did ultrasound alone have any impact on the patient's management. Four children with both abnormal-appearing renal ultrasound and voiding cystourethrography required surgical intervention. One hundred of the 124 children had a voiding cystourethrogram. In 38 children it detected vesicoureteral reflux and, in another two, bladder abnormalities. Thirty-five of those with abnormal-appearing cystogram but without an indication for surgery were given prophylactic antibiotics. During the same 25-month period, 63 children without urinary tract infection were diagnosed by ultrasound with hydronephrosis. In 45 of them (71.4%) the urologic abnormality had already been detected by prenatal ultrasound. Fourteen of these 45 children (31.1%) required surgery, all for congenital anomalies related to obstructive uropathy. We conclude that routine renal ultrasonography in children with first urinary tract infection has negligible influence on their clinical management. This seems to be due to the recent widespread use, in industrialized countries, of maternal-fetal ultrasonography, which already detects a significant number of children with congenital obstructive uropathy prenatally. On the other hand imaging of the lower urinary tract is of high yield and contributes significantly to patient care. Therefore, whereas imaging of the lower urinary tract should continue to be done routinely in children with first urinary tract infection, renal ultrasound may be reserved for more select cases.     

Responses of natural killer cell activity to acute laboratory stressors in healthy men at different times of day

BACKGROUND: Five renal recipients with neurovesical dysfunction (NVD) were retrospectively reviewed focusing on anatomical and urodynamic abnormalities of the lower urinary tract and their management prior to kidney transplantation. METHODS: The underlying anomalies in these 5 patients were a posterior urethral valve (1 with an imperforate anus; n = 2), meningomyelocele (n = 2) and a congenital short urethra with an imperforate anus (n = 1). Their urinary tracts were evaluated prior to transplantation with voiding cystourethrography, urethrocystoscopy, cystometrography and electromyography of the external urethral sphincter to identify a possible focus of urinary tract infection, urine storage and voiding function. RESULTS: All 5 patients had NVD proven by urodynamic studies or by documentation of urinary retention in the absence of mechanical outlet obstruction. Bilateral high grade vesicoureteral reflux was noted in all patients, requiring ureteroneocystostomy. Clean intermittent catheterization (CIC) was ultimately employed for bladder emptying in all patients. Two patients with poor bladder compliance underwent augmentation cystoplasty before transplantation. The Mitrofanoff procedure was used in 2 patients with structural urethral abnormalities to access the bladder for catheterization. After eradication of possible sources of infection and establishment of a low-pressure urine storage system with bladder emptying by CIC, kidney transplantation was performed. Following kidney transplantation, all of the recipients were asymptomatic for urinary tract infections using CIC. Although 1 patient lost his graft due to chronic rejection, the other 4 other patients have good renal function. CONCLUSION: Kidney transplantation in patients with NVD can be performed provided that their urinary tract problems are properly resolved.     

Oral administration of tritiated water (HTO) in mouse. III: Low dose-rate irradiation and threshold dose-rate for radiation risk

Primary vesicoureteric reflux (VUR) diagnosed on investigation of foetal hydronephrosis accounts for many antenatally detected uropathies. In order to study foetal VUR and its consequences, newborns with foetal hydronephrosis were investigated by ultrasound, micturating cystourethrogram and 99mTechnetium-dimercapto-succinic acid (DMSA), after beginning of chemoprophylaxis. Twenty-eight infants with VUR (bilateral in 15 cases) were identified giving a total 43 renal units for study. There was a predominance of males (86%), moderate/severe reflux (84%) and renal damage (51%). Presence of renal damage was correlated with the severity of reflux. VUR should be investigated in cases of foetal hydronephrosis and our results support that renal damage is frequently congenital and not secondary to urinary tract infection.     

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.     

Diagnostic value of procalcitonin: the influence of cardiopulmonary bypass, aprotinin, SIRS, and sepsis

We report the perinatal findings in a male fetus with congenital megacystis and anorectal malformations. A 17-year-old primipara was referred to our department at 13 weeks of gestation for management of a 4.6 x 3.8 cm massive intra-abdominal fetal mass consistent with megacystis. The fetal thorax was severely compressed. We used a 22-gauge needle to perform intrauterine fetal vesicocentesis, removing 30 ml of fetal urine, decreasing the fetal bladder diameter/crown-rump length ratio from 65.7 to 17%. Cytogenetic analysis revealed a 46, XY karyotype. Intermittent bladder aspiration was performed weekly from 13 to 20 weeks of gestation and every 2-3 weeks from 21 to 35 weeks of gestation for the purpose of decompression. Mild dilation of both renal pelves was noted beginning at 20 weeks of gestation, however, neither progression of hydronephrosis nor development of oligohydramnios was noted. At 36 weeks of gestation, a live male neonate was delivered with a normal phallus, duodenal atresia, mild congenital heart defects, a distended bladder, bilateral hydronephrosis, megaureters, imperforate anus with rectovesical fistula, cryptorchidism and bilateral vesicoureteric reflux. The postnatal renal function was normal. He underwent serial operations including colostomy, anoplasty with repair of rectovesical fistula, duodeno-duodenostomy, bilateral re-implantation of ureters, orchiopexy and reduction cystoplasty. At 20 months of age, the child had normal renal function. The intravenous pyelogram showed normal functional kidneys, moderate megaureters and moderate megacystis. He underwent clean intermittent catheterization for residual urine. The recurrent urinary tract infections were under control.     

Asphyxiated bladder syndrome in a pediatric intensive care unit

Sixteen neonates and infants with asphyxiated bladder syndrome (ABS) were prospectively studied over a two-year period. Their transient urinary bladder distention had developed as a sequel of asphyxial events, and presented as delayed micturition in the absence of obstructive lesion. The incidence was 1.9 percent in this Pediatric Intensive Care Unit. Five cases occurred in the neonatal period. All patients were younger than three years of age (mean: 9.1 months), and the incidence of ABS was 2.8 percent within this age group. For intermittent decompression of the bladder, all responded successfully to the suprapubic bladder expression method (Crede's maneuver). Most (81.3%, 13/16) ABS cases coexisted with intestinal dysfunction as either paralytic ileus (62.5%, 10/16) or as gas-less abdomen (18.8%, 3/16). There was no evidence of association with either systemic or urinary bacterial infection. Normal spontaneous voiding and bowel function were regained in all cases except one, who died early. Mean (SD) duration of bladder dysfunction was 66.9 (40.3) hours. Sonography showed normal kidneys and collecting system in all patients both during and after ABS episodes. Half of the patients (8/16) died ultimately. No urinary tract abnormality was found in post-mortem examinations in five cases.     

Posterior urethral valves after infancy-urodynamic consequences

This study describes a subset of patients with posterior urethral valves (PUV) who presented late in childhood. The objective was to identify factors that lead to back-pressure effects on the upper tracts, which persist in spite of adequate valve ablation in some patients, and seek factors that may preserve the upper tracts despite untreated obstruction in other patients. Six children with PUV diagnosed after infancy were evaluated. The pre-operative work-up included renal biochemistry, ultrasonography, voiding cystourethrography, and uroflowmetry. Detailed urodynamic studies, including uroflowmetry and slow-fill cystometry, were performed in all cases 6 months after surgery. Adequacy of valve fulguration was confirmed by urethroscopy. Three of the six patients had normal upper tracts; in these, there was marked improvement in peak urine flow rates after fulguration and bladder pressures were normal. The other three patients had bilateral hydroureteronephrosis, and two had chronic renal failure. This group had markedly decreased functional bladder capacity with loss of compliance at low bladder volumes and significant residual urine volumes in spite of adequate valve fulguration, suggesting myogenic detrusor failure. We conclude that in patients with PUV presenting beyond the age of 5 years, upper-tract deterioration may accompany high storage pressures in the bladder. In some boys with long-standing obstruction the upper tracts may escape damage; in our series this was associated with normal bladder dynamics and appeared unrelated to the severity or duration of outflow obstruction.     

Acute renal failure due to oxalate ingestion

Analysis of the infiltrant tumours of the bladder diagnosed in our service between 1986-1996 both inclusive, with associated tumour of the upper tract during its evolution. From a total of 262 infiltrant transitional tumours of the bladder and 52 transitional tumours of the upper urinary tract, 8 patients were found to have both types of tumours in association, which accounted for 3.05% of all infiltrant vesical tumours. Mean age of our patients, all male, was 65. The pathological anatomy of the upper tract tumours was: 4 pT1 and 4 pT3. 75% presented relapsing tumours of the bladder, 50% had a background of bladder Cys, 87.5% were multifocal vesical tumours and 100% were larger than 3 cm. In addition, 62% cases were ipsilateral to the tumours of the upper urinary tract. It can therefore be concluded that for tumours of the bladder, multifocality, relapse, presence of vesical Cys and tumour size, are all concurring features when association of these two types of tumours occurs.     

Recurrent urothelial tumors following surgery for transitional cell carcinoma of the upper urinary tract

A retrospective analysis of 74 cases of transitional cell carcinoma of the renal pelvis and ureter treated at this institution over the past 30 years is presented. When nephrectomy alone or incomplete nephroureterectomy was performed, subsequent transitional cell carcinoma developed in 30% of the ureteral stumps. Subsequent bladder carcinoma occurred in 25% of the patients with primary upper urinary tract carcinoma. The type of initial surgery performed did not appear to influence this incidence of subsequent bladder tumors. Contralateral upper urinary tract carcinoma developed in only one patient. When nephroureterectomy is performed for carcinoma of the renal pelvis and ureter, a cuff of bladder that includes the ureteral orifice should be removed to obviate recurrent disease in the ureteral stump. Since single-incision nephroureterectomy did not include the intramural ureter in 50% of the cases in which it was performed, a second incision may be required for adequate exposure.     

A case of ureteral tuberculosis appearing as a ureteral tumor

A 53-year-old female was admitted to our hospital after right hydronephrosis was found on the CT scan taken at another hospital. The urinary cytology and culture findings as well as the urinary culture for acid-fast bacilli results were all negative. At our hospital, CT scan revealed a thickening of the right ureteral wall, and right hydronephrosis. In spite of the fact that retrograde pyeloureterography showed a right ureteric obstruction at the ureterovesical junction, cystoscopic examination demonstrated a normal bladder. Since right lower tract carcinoma was suggested, we performed right nephroureterectomy with bladder cuff. Histopathological diagnosis, however, revealed renal and ureteral tuberculosis.     

Genitourinary anomalies in the CHARGE association

PURPOSE: We identified the incidence and types of genital and urinary anomalies, and established a plan for evaluating the urinary system in the CHARGE association. MATERIALS AND METHODS: We retrospectively reviewed the charts of 32 patients in whom the CHARGE association was diagnosed. RESULTS: Of the 32 patients identified 22 (69%) had genitourinary abnormalities. Genital anomalies, including micropenis, penile agenesis, hypospadias, chordee, cryptorchidism, a bifid scrotum, atresia of the uterus, cervix and vagina, and hypoplastic labia majora, labia minora and clitoris, were present in 18 patients (56%). Of the 24 patients who underwent renal ultrasound 10 (42%) were diagnosed with urinary tract anomalies including a solitary kidney, hydronephrosis, renal hypoplasia and duplex kidneys. Further evaluation revealed vesicoureteral reflux, neurogenic bladder secondary to spinal dysraphism, nephrolithiasis, ureteropelvic junction obstruction and a nonfunctioning upper pole in both duplex kidneys. CONCLUSIONS: There is a high incidence of genitourinary anomalies in the CHARGE association. Because of this high incidence of anomalies, patients with this condition should undergo a careful genitourinary evaluation, including renal and bladder ultrasound, and voiding cystourethrography screening.     

Disseminated intravascular coagulation: pathophysiology and principles of management

OBJECTIVE: To analyze the survival and the main prognostic factors in patients with transitional cell carcinoma of the upper urinary tract. METHODS: From 1983 to 1996, we treated 50 patients with transitional cell carcinoma of the upper urinary tract. Treatment was basically conservative except in those cases whose tumor stage or grade required a radical approach. Grading and staging were performed according to the 1992 TNM classification. Eighteen patients had died at one year mean follow-up., At the time the study was completed (June, 1997), 32 patients were alive with a mean follow-up of 4.9 years. Disease-free survival, overall and specific survival were analyzed according to sex, age, association with bladder tumors, localization, type of treatment, tumor size, number, histological grade and stage. RESULTS: The male-to-female ratio was 5:1. Patient mean age was 65.7 years. Association with bladder tumors was observed in 50%. Treatment was conservative in 40% and radical in 60%. The five- and ten-year disease-free survival rates were 69%, overall survival 61% and specific survival 71%. The univariate analysis showed the following to be unfavorable prognostic factors for survival: renal vs ureteral tumors, radical vs conservative treatment, high grade and stage tumors. The association of carcinoma in situ with other tumors of the upper urinary tract was also found to be an unfavorable factor for disease-free survival. The multivariate analysis associated T4 and G3 tumors with poor prognosis. CONCLUSIONS: Transitional cell carcinoma of the upper urinary tract was associated with bladder tumors in 50% of the cases. Low grade stage tumors demonstrated a high survival rate, therefore conservative treatment should be the first approach. High grade/ stage tumors were found to be unfavorable prognostic factors for survival.     

Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.     

Current aspects in the diagnosis and treatment of chronic cystitis in women

Chronic cystitis (CC) in females is annually encountered now in 15,000-20,000 per 1,000,000. Etiological and pathogenetic factors in CC are closely related. Bacteriologically, CC is represented primarily by Enterobacter. The infection, as a rule, ascends the lower urinary tracts. The contributing factors are: weak local antibacterial mechanisms of the urogenital system, anatomical variants and anomalies of the urethra and introitus, sexual activity, impaired urodynamics of the lower urinary tracts. The diagnosis of chronic inflammation of the bladder is made mainly endoscopically, with obligatory endovesical multifocal biopsy of the bladder followed by histological examination. The treatment of CC includes antibacterial, general and local antiinflammatory therapy, measures to normalize urodynamics of the lower urinary tracts, correction of hygienic and sexual factors, immunostimulation. 16 nonresponders to conservative treatment of interstitial cystitis with progressive contraction of the bladder were subjected to supratrigonal or subtotal resection of the bladder with one-stage ileocystoplasty.     

Vesicorectostomy revisited

Between 1948 and 1959 vesicorectostomy, a permanent anastomosis between the bladder and rectum, was constructed in 7 male patients. Scattered reports of this procedure exist but none since 1959 and long-term followup has never been reported. we present long-term followup, including renal function, excretory urography and voiding cystorectography, and review the quality of life in the 7 patients. The most frequent complication was stenosis of the anastomosis. None of the patients in this series with normal preoperative upper tracts showed radiographic or chemical deterioration postoperatively. Since this procedure maintains urinary continence, does not disturb the normal physiology of the ureterovesical junction and minimizes urinary reabsorption its use should be considered in certain patients as an alternative method of urinary diversion.     

Enterocystoplasties: results in 22 children

A study of paediatric enterocystoplasty in 22 children of 1 to 14 years of age (M = 8) during 5 years is presented. The diagnoses were: neurogenic bladder 16 (73%), extrophic bladder 3, urethral valves 1, and complex uropathies 2. The intestinal segments used were: ileum 12 cases, sigmoid 8, and ileocaecal region 2 (non myelodisplastic). During the last years sigmoid have been preferred due to its bigger size. The middle follow up is 3.5 years (R 1-6). The results have been good in: renal function 86%, and upper urinary tract 95%. Bladder capacity was 278% higher, bladder pressure was 82% less, and residual urine was 217% more, than preoperatively. Five children developed 6 complications (23%), and 4 reinterventions were performed (18%). When it is indicated, paediatric enterocystoplasty is a good alternative to urinary diversion, and it is useful to prevent the upper urinary tract deterioration; but a frequent and, all the life long follow up is necessary, due to its possible complications.     

Tensions in setting health care priorities for South Africa''s children

Intractable detrusor overactivity can result in considerable morbidity and, in the case of neurogenic bladder dysfunction, can put the upper tracts at risk. Once conservative treatments have been exhausted the aim of surgery is to increase functional bladder capacity and decrease the maximal detrusor pressure at this capacity. The mainstay of contemporary therapy has been augmentation cystoplasty; the different techniques and recent literature are reviewed herein. Bladder autoaugmentation is compared and contrasted with augmentation cystoplasty and its role is discussed, as is the less invasive technique of sacral neuromodulation with reference to their role within the range of surgical treatments for detrusor activity.