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1.
OBJECTIVE
To apply stereotactic electrical stimulation of the pig brainstem and thus identify a pontine micturition centre.MATERIALS AND METHODS
In 10 anaesthetized female Vietnamese minipigs a needle‐electrode was positioned in the pontine region. Pressure responses in the lower urinary tract identified the micturition centre functionally during electrical stimulation. Stereotactic coordinates were recorded, and the needle visualized by fluoroscopy, magnetic resonance imaging (MRI) or histologically.RESULTS
The stimulation evoked responses similar to voiding, i.e. a urethral pressure decrease followed by a bladder pressure increase; or similar to a continence manoeuvre, i.e. urethral pressure increase and no change in bladder pressure. In a few cases a continence response was evoked by stimulating a site 1 mm away from the site where a voiding response was evoked. The electrode position was detected by the fluoroscopy‐based stereotactic procedure followed by subsequent MRI (one animal), and by histological analysis, verifying it to be in the dorsolateral pontine region.CONCLUSIONS
These results show that a pontine micturition centre exists in pigs similar to that described in rats, cats, dogs and humans.2.
Seif C Cherwon E Martinez Portilló FJ Alken P Jünemann KP Braun PM 《BJU international》2003,91(7):711-715
OBJECTIVE
To investigate different stimulation signals for the peripheral nerve evaluation test (PNE, carried out before implanting a sacral neuromodulator for functional voiding dysfunction) in an animal model and to determine their efficacy, as up to 80% of patients do not respond to the PNE test.MATERIALS AND METHODS
PNE foramen electrodes were placed in the S3 of 12 anaesthetized Göttingen minipigs. First, detrusor instabilities were induced by the intravesical instillation of formalin. A 10‐min stimulation phase with both a quasi‐trapezoidal (QT) signal and a rectangular signal followed. An interval of 30 min elapsed between the series of stimulations. The attained bladder pressure values were registered on a urodynamic unit and evaluated as contractions and amplitudes per minute. Six minipigs were treated in the same way but were not stimulated and served as a control group.RESULTS
After formalin instillation, the mean (sd ) number of involuntary detrusor contractions was 3.5 (0.8)/min and the sum of amplitudes 7.2 (1.1) cmH2O/min. Subsequent NaCl instillation and QT‐stimulation reduced the contractions to 0.3 (0.3)/min and the sum of amplitudes to 0.8 (0.4) cmH2O/min. Stimulation with a rectangular signal, as used in the PNE test, followed after an interval of 10 min, giving 1.1 (0.1) contractions/min and a sum of amplitudes of 5.1 (2.4) cmH2O/min. Within the control group there was no significant reduction.CONCLUSIONS
These results show that QT‐stimulation suppresses uncontrollable detrusor contractions in the minipig more effectively than the conventional rectangular stimulation presently applied in sacral neuromodulation.3.
OBJECTIVE
To review the long‐term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6‐year period at one tertiary referral centre.PATIENTS AND METHODS
Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow‐up, complications and revision procedures, and the most recent uroflowmetry results.RESULTS
There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant‐related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s.CONCLUSION
In young women with retention, for whom there is still no alternative to lifelong self‐catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.4.
OBJECTIVE
To report a retrospective study evaluating the management of superficial urethral recurrence after ileal neobladder construction in patients with bladder cancer.PATIENTS AND METHODS
In 77 consecutive patients with ileal neobladder after radical cystectomy for invasive bladder cancer, urethral recurrence was evaluated and transurethral resection (TUR) used as an initial treatment for superficial urethral recurrence. Urethrectomy with urinary re‐diversion was performed when further recurrence developed.RESULTS
Four patients (5%) presented with a superficial urethral recurrence and all four were treated by TUR as initial therapy. One patient has had no evidence of recurrence after initial TUR, although the other three patients were later treated with salvage urethrectomy due to repeated urethral recurrence. As a result, the stage of urethral recurrence advanced from pTa to pT1–pT2 in two of the three patients. For urinary re‐diversion, one patient had a conversion from a Studer pouch to an ileal conduit, using the afferent limb, and the other two were converted from a Hautmann pouch to a continent reservoir using the Appe‐Mainz procedure. There was no evidence of metastasis or local recurrence in any of the four patients.CONCLUSION
Urethral preservation at initial therapy for superficial recurrence might be reasonable, and sequential urethrectomy after attempted urethral preservation might be strategically feasible. Urinary re‐diversion from a neobladder to a catheterizable continent reservoir using the appendix would be a good choice and maintains the quality of life.5.
OBJECTIVE
To correlate urine cytology findings before and after flexible cystoscopy.PATIENTS AND METHODS
A total of 153 patients undergoing surveillance for bladder tumour provided voided urine for cytology before and immediately after flexible cystoscopy.RESULTS
Of the 153 patients, 116 had negative urine cytology before and after (96%) a visibly normal cystoscopy and 37 had positive urine cytology before and after cystoscopy that showed recurrent tumour.CONCLUSIONS
Urine cytology immediately after flexible cystoscopy correlates well with results of urine cytology before cystoscopy.6.
Mouriquand PD Bubanj T Feyaerts A Jandric M Timsit M Mollard P Mure PY Basset T 《BJU international》2003,92(9):997-1001; discussion 1002
OBJECTIVE
To review the long‐term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve ‘continence’ (which implies active mechanisms) but only ‘dryness’ (which implies passive mechanisms).PATIENTS AND METHODS
Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young‐Dees‐Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow‐up of 11 years. All patients were treated and followed in the same institution.RESULTS
In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty‐eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery.CONCLUSION
We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.7.
OBJECTIVE
To evaluate the morbidity and mortality of radical cystectomy in a group of unselected patients aged ≥ 75 years who were treated with curative and palliative intent.PATIENTS AND METHODS
We retrospectively analysed 53 patients aged 75–90 years (median 78.8 years) who had radical cystectomies between May 1994 and July 2002. The patients were divided into two groups: 46 were treated with curative intent (group A) and seven with palliative intent (group B). The indications for cystectomy in group A were recurrent and otherwise therapy‐resistant bladder cancer, severe irritative voiding symptoms, and recurrent macrohaematuria. The indications in group B were advanced pelvic malignancy with severe irritative voiding symptoms, severe pain, and recurrent macrohaematuria requiring blood transfusions. Patients were categorized according to the American Society of Anesthesiologists classification, with a score of II in 28 patients, III in 21 and IV in four. Complications and mortality before, during and after surgery, and the duration of hospital stay and clinical outcome, were assessed.RESULTS
The early mortality rate in group A was 4% (2/46); in group B two patients died after prolonged complications. The median (range) hospital stay was 28 (6–56) days, and was significantly longer in patients with complications, at a median (range) of 36 (6–70) days. The complication rates early and late after surgery in group A were 22% and 11%, respectively, and in group B, five of seven (early). The total median survival was 2 (0.33–7) years.CONCLUSIONS
Elderly people undergoing radical cystectomy have a greater risk of perioperative morbidity and mortality, especially those with very advanced pelvic malignancies who have had cystectomy with palliative intent. The incidence of early and late complications in patients treated with curative intent is acceptable, but the hospital stay is prolonged.8.
Van Der Horst C Martínez Portillo FJ Seif C Alken P Juenemann KP 《BJU international》2004,93(1):105-108
OBJECTIVES
To investigate retrospectively the long‐term functional results and quality of life of patients undergoing the Essed‐Schröder procedure (a simple plication of the tunica albuginea) to correct penile deviation, using a standardized questionnaire.PATIENTS AND METHODS
Between 1998 and 2001, 59 patients had surgery in our hospital to correct penile deviation (mean age 40 years at the time of surgery; mean follow‐up 30 months for this study). All 59 patients received a standardized questionnaire via mail, of which 50 could be assessed as valid.RESULTS
Of the 50 patients, 22 had a congenital penile deviation and 28 Peyronie's disease. In all patients the penis was completely straightened. The proportion of patients capable of sexual intercourse was significantly higher after surgery (90%) than before (62%). The frequency of pain during intercourse was halved. Of the 50 patients, 60% would have the same operation again, 32% were undecided and 8% would not; 22% were dissatisfied with the results. None of the patients had complete erectile dysfunction after surgery; 74% reported a decrease in penile length and 78% of the patients’ partners were satisfied with the outcome.CONCLUSIONS
The tunical plication procedure is simple and minimally invasive for correcting penile deviation. In the opinion of most patients the Essed‐Schröder method provides a significant improvement in sexual function and quality of life with maximum protection of erectile function.9.
OBJECTIVE
To evaluate the long‐term results of one‐stage perineal anastomotic urethroplasty for post‐traumatic paediatric urethral strictures.PATIENTS AND METHODS
Thirty‐five boys who had a perineal anastomotic urethroplasty for post‐traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6–132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto‐urethrography.RESULTS
The mean (range) age of the patients was 11.9 (6–18) years. The estimated radiographic stricture length before surgery was 2.6 (1–5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow‐up.CONCLUSIONS
The overall success of a one‐stage perineal anastomotic repair of post‐traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino‐perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.10.
Friedrich MG Toma MI Hellstern A Pantel K Weisenberger DJ Noldus J Huland H 《BJU international》2003,92(9):911-914
OBJECTIVES
To present a single‐centre study investigating aneuploidy at chromosomes 3, 7, 17 and 9p21 (e.g. loss at 9p21) using a multitarget fluorescence in situ hybridization (FISH) system, as identifying genetic alterations in urine specimens is a promising approach for the noninvasive detection of bladder cancer.PATIENTS AND METHODS
Urine samples from 103 patients were evaluated, including those from 46 with histologically confirmed urothelial carcinoma, two with other urological malignancies, and 55 who acted as controls. The urine samples were taken before any manipulation. The validity of FISH (Urovision, Vysis, Downers Grove, Ill, USA) was compared with other noninvasive urine tests, including the BTA‐Stat test, the nuclear matrix protein (NMP)‐22 test, and immunocytology against 486p3/12 and LewisX. Those evaluating the tests were unaware of the clinical and histopathological data. FISH was considered positive if five or more urinary cells had gains of two or more chromosomes. The threshold for the urine tests were 10 U/mL (NMP‐22), 30% positive cells (486p3/12), or 5% positive cells, respectively (LewisX).RESULTS
The sensitivity was 69% (FISH), 67% (BTA‐Stat), 69% (486p3/12), 96% (LewisX) and 71% (NMP22), respectively; the respective specificity was 89%, 78%, 76%, 33% and 66%.CONCLUSION
Multitarget FISH had a better specificity than the other urine markers but because of its inadequate sensitivity it does not seem to be powerful enough to replace endoscopy. Optimizing the marker panel could provide a higher sensitivity.11.
Glutamatergic cells in the periaqueductal gray matter mediate sensory inputs after bladder stimulation in freely moving rats 
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下载免费PDF全文 Aryo Zare Ali Jahanshahi Celine Meriaux Harry WM Steinbusch Gommert A van Koeveringe 《International journal of urology》2018,25(6):621-626
Objectives
To determine the phenotype of the ventrolateral part of the periaqueductal gray matter neurons after bladder stimulation.Methods
In the experimental group, electrical stimulation of the bladder was carried out under freely moving condition by a bipolar stimulation electrode implanted in the bladder wall. Thereafter, the brain sections were processed for immunohistochemical analysis using antibodies against c‐Fos (neuronal activation marker) together with one of the following: tyrosine hydroxylase (dopaminergic cell marker), vesicular glutamate transporter (glutamatergic cell marker), serotonin, glutamate decarboxylase (glutamate decarboxylase 67, gamma‐aminobutyric acid cell marker) and neuronal nitric oxide synthase. We used design‐based confocal stereological analysis to quantify the immunohistochemically stained sections.Results
A significant increase in the number of c‐Fos‐positive cells in the ventrolateral part of the periaqueductal gray matter after stimulation was found. Furthermore, the ratio of c‐Fos cells double labeled with vesicular glutamate transporter was significantly higher in the ventrolateral part of the periaqueductal gray matter region in the stimulated compared with the sham group. Quantitative analysis of the other four cell types did not show any significant difference.Conclusion
These findings suggest that glutamatergic neurotransmission in the ventrolateral part of the periaqueductal gray matter is seemingly the main pathway to be activated after receiving sensory signals from the bladder.12.
OBJECTIVE
To highlight the current status of ureteroscopic endoureterotomy (UE) by reporting extensive experience with the endoscopic management of ureteric strictures, with special emphasis on factors determining success, and by reviewing publications on the minimally invasive management of ureteric strictures.PATIENTS AND METHODS
The study comprised 50 patients (mean age 53 years, range 18–85, equal sex distribution) with ureteric strictures of varying causes; all had their stricture treated endoscopically. The follow‐up was 0.5–9 years; 10 patients with recurrent strictures had two ipsilateral stents placed to try to improve the outcome, and eight patients with completely obliterating strictures were treated by ureteroscopic re‐canalization.RESULTS
The site of stricture had no bearing on the eventual outcome. Patients with uretero‐enteric and malignant strictures did not fare so well. The most important predictor of failure was the length of the stricture, with failure in all seven patients with strictures of > 2 cm. In the 10 patients treated with two ipsilateral stents, eight were successful, which was very promising considering that these patients had recalcitrant strictures and placing one stent had previously failed. The overall success rate was 74%.CONCLUSION
UE has become the procedure of choice for the initial management of ureteric strictures. Simple balloon dilatation is also effective in certain situations. The characteristics of the stricture often govern the eventual outcome. In properly selected cases success rates of ≈ 75% can be expected.13.
OBJECTIVE
To investigate whether the gonadotrophin‐releasing hormone (GnRH) test is an adequate diagnostic tool to identify testicular dysfunction in men with strictly unilateral varicocele and defined testicular volume; and to identify any peripheral venous variable which would predict the result of the GnRH test.PATIENTS AND METHODS
In all, 102 GnRH tests were done in men with a left‐sided varicocele. Follicle‐stimulating hormone (FSH) and luteinizing hormone (LH) levels were determined. After intravenous administration of 100 µg GnRH, stimulated LH and FSH levels were measured. FSH levels of >8.2 U/L and LH levels of >51.7 U/L were considered exaggerated.RESULTS
In all, 50 men had an exaggerated GnRH test result; all had an exaggerated FSH response and six also had an elevated LH response. The baseline FSH levels were higher (P < 0.001) and the testicular volume was smaller (P < 0.01) in men with an exaggerated GnRH test response. All men with a baseline FSH level of >5.6 U/L had an exaggerated GnRH test response.CONCLUSION
A baseline FSH level of >5.6 U/L is a good predictor of the GnRH test outcome. Leydig cell function seems mainly undisturbed.14.
Van Brummen HJ Bruinse HW Van de Pol G Heintz AP Van der Vaart CH 《BJU international》2006,97(2):296-300
OBJECTIVE
To evaluate the effect of overactive bladder symptoms (OAB) on women's quality of life (QoL) during and after the first pregnancy, using self‐reported symptom‐based QoL questionnaires.PATIENTS AND METHODS
In a prospective cohort study, 474 women were asked to complete four self‐reported questionnaires. Urogenital symptoms were assessed with the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). A women was considered to experience ‘dry’ OAB if she replied positively to the following two questions: ‘do you experience a strong feeling of urgency to empty your bladder?’; and ‘do you experience frequent urination?’. A women was considered to experience ‘wet’ OAB if she replied positively to all of the following questions: ‘do you experience a strong feeling of urgency to empty your bladder?’; ‘do you experience frequent urination?’; and ‘do you experience urine leakage related to the feeling of urgency?’.RESULTS
In all, 344 (72.6%) women who returned all four questionnaires were included in the analysis. After first childbirth there was a rapid decline in the prevalence of dry OAB (45.2% to 7.9%, P < 0.001). In pregnancy the prevalence of wet OAB increased significantly, but a year after childbirth the prevalence of wet OAB decreased and was similar to that at 12 weeks of gestation (P = 0.289). Women with wet OAB had higher scores on all IIQ domains than those with no OAB symptoms at 36 weeks of gestation. Women with dry or wet OAB all had higher scores on the mobility domain than those with no OAB. The scores on the physical, social and emotional functioning domains were low, suggesting a minimal restriction of lifestyle.CONCLUSION
OAB symptoms are common during pregnancy; dry OAB had no negative effect on QoL, whereas wet OAB compromised QoL both during and after pregnancy, mainly in the ‘mobility’ and ‘embarrassment’ domains. The urge urinary incontinence symptom in wet OAB seems to profoundly compromise QoL. Apparently, in young mothers with wet OAB, limitations in mobility are especially stressful and these symptoms can be embarrassing.15.
OBJECTIVE
To review different treatment strategies for women with groin pain after tension‐free vaginal tape (TVT) or similar suburethral sling procedures.PATIENTS AND METHODS
The series comprised 450 women who had a TVT procedure, with a follow‐up of 3–50 months. Five women (1%) reported significant groin pain and were offered further treatment. In addition, one woman was referred from another centre and received treatment.RESULTS
Women with pain were initially treated conservatively, and in most the pain resolved and required no further treatment. Persistent or severe discomfort was treated with a combined steroid (methyl prednisolone, 2 mL, 80 mg) and local anaesthetic (bupivacaine, 10 mL, 0.5%) injection in four women. There were no side‐effects from the treatment. One woman was relieved of her pain and required no further treatment. In one woman the local injections failed to improve her symptoms but the pain was not severe enough to warrant further treatment. Two women developed recurrent pain after an initially successful injection, and in these women the TVT was excised. One woman referred from another centre was primarily treated with TVT excision. In the three women treated with distal tape excision, the mean pain scores decreased from 8.7 before excision to 0.7 afterward. One woman is awaiting tape excision.CONCLUSION
If conservative management fails to relieve the symptoms of groin pain it can be treated by injecting a mixture of steroid and local anaesthetic. However, local injection failed to provide long‐term relief in three of four women. More severe symptoms might require TVT mesh dissection and excision, which provided significant pain relief.16.
OBJECTIVE
To investigate the effects of hypercholesterolaemia (HC) on rabbit corpus cavernosa in vivo and in vitro, and evaluate the efficacy of vardenafil and sildenafil in normal and HC rabbits, as the phosphodiesterase‐5 (PDE‐5) inhibitors vardenafil and sildenafil are widely used for treating erectile dysfunction (ED) and most organic causes of ED are associated with vascular risk factors like HC.MATERIALS AND METHODS
Male New Zealand White rabbits were randomly divided into two groups; 11 HC rabbits were fed a 2% cholesterol diet, and 12 age‐matched control rabbits received a regular diet. After 12–14 weeks, erectile responses to intravenous sodium nitroprusside (SNP) and PDE‐5 inhibitors were evaluated for 2 h in conscious rabbits. Penile length was measured and the area under the curve calculated. Relaxant responses of corpus cavernosal strips to electrical‐field stimulation (EFS) were measured before and after exposure to PDE‐5 inhibitors and the nitric oxide synthase inhibitor N′‐nitro‐ l ‐arginine methyl ester.RESULTS
HC rabbits had a lower erectile response to SNP than controls; in both control and HC rabbits there was a greater erectile response after simultaneous exposure to SNP and vardenafil, or SNP and sildenafil. However, the responses of the HC rabbits were still significantly less than those of the controls. Corpora from control rabbits responded to EFS with greater relaxations at all frequencies, except 1 Hz. Corpora from both HC and control rabbits had greater responses to EFS after exposure to vardenafil and sildenafil; N′‐nitro‐ l ‐arginine methyl ester diminished the response to EFS.CONCLUSIONS
There was a significantly lower in vivo and in vitro erectile response in HC rabbits than in controls; erectile function measured in conscious rabbits can be used to assess quantitatively the efficacy of different agents, e.g. sildenafil and vardenafil, in pathological animals. In addition, both agents improve in vitro responses of erectile tissue from HC rabbits to EFS.17.
OBJECTIVE
To compare the efficacy and safety of sildenafil and apomorphine in the treatment of men with erectile dysfunction (ED).PATIENTS AND METHODS
In all, 139 men with ED who were naïve to treatment were entered into an open‐label crossover trial with two treatment periods, each of 8 weeks, separated by a 2‐week washout period. Men were randomized to receive either sildenafil then apomorphine or apomorphine then sildenafil, and were allowed to titrate the dose on both drugs. The primary endpoint was the erectile function (EF) domain of the International Index of Erectile Function (IIEF), and other endpoints included diary data, the other domains of the IIEF, overall assessment questions and the Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire.RESULTS
The EF domain score after treatment was 25.2 for sildenafil and 15.9 for apomorphine. The treatment difference of the adjusted means was 9.3 points (95% confidence interval 7.6–11.1; P < 0.001). After sildenafil the successful intercourse rate was 75%, vs 35% for apomorphine (P < 0.001), and the EDITS scores were 82.5 for sildenafil and 46.8 for apomorphine (P < 0.001). Of the men, 96% expressed a preference for sildenafil as a treatment for their ED. The side‐effect profiles for both drugs were in keeping with published data.CONCLUSION
By all measurable endpoints sildenafil was superior to apomorphine in this open‐label crossover study of men with ED who were naïve to therapy18.
OBJECTIVE
To assess the long‐term results in children with high‐grade renal trauma who were managed without surgery, as such treatment was initially successful but little is known about the late ipsilateral renal function and morphology.PATIENTS AND METHODS
The study included 13 children (nine boys and four girls; mean age 8 years, sd 5) with high‐grade renal injury who were managed without surgery between 1997 and 2001, and followed for a mean (sd , range) of 3 (2, 0.5–7) years. The trauma was caused by a motor‐car accident in five and falling from a height in eight children, and was on the right in 10 and on the left in three. There was gross and microscopic haematuria in 10 and three patients, respectively. The trauma was graded according to the American Association for Surgery of Trauma, with grades III, IV and V renal injury in six, four and three children, respectively. All patients were treated initially by observation; one required super‐selective embolization because of continuing haemorrhage. Three children with progressive urinary extravasation were treated with a percutaneous tube drain and JJ stent for 6 weeks. Patients were discharged after a mean (sd ) hospital stay of 9 (6) days. Ultrasonography then showed resolving haematoma in all patients with a mean (sd ) size of 7 (2) cm2. At the last follow‐up patients were re‐evaluated by a clinical examination, renal scintigraphy and computed tomography angiography.RESULTS
None of the children was hypertensive nor had any abnormality on urine analysis; all had normal serum creatinine levels, and scintigraphy and angiography showed normal contralateral kidneys in all. Ipsilateral abnormalities were detected in 12 patients, and included a single scar in five, multiple scars in six and a cystic lesion with multiple septa in one. There was no vascular complication or hydronephrosis, and no significant functional loss, with all affected kidneys having a split function of 41–50% at the last follow‐up.CONCLUSION
Although there is no late functional loss there are residual morphological changes in almost all children with high‐grade renal injury. This study provides objective support for the non‐operative management of high‐grade renal injury in children, but a prolonged follow‐up is warranted to assess the risk of progression of these abnormalities.19.
Moreira SG Seigne JD Ordorica RC Marcet J Pow-Sang JM Lockhart JL 《BJU international》2004,93(1):31-35
OBJECTIVE
To report a retrospective chart review of patients who developed recto‐urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer.PATIENTS AND METHODS
In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60–81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York‐Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization.RESULTS
All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York‐Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty.CONCLUSIONS
Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York‐Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.20.