Cystourethrograms characteristic of bladder instability in children

Cystourethrograms characteristic of bladder instability are illustrated. A repeated increase of intravesical pressure causes functional and morphologic deformities of vesicourethral configuration: ballooning of the proximal urethra, ureteric reflux, and trabeculated bladder during the storage phase; and dilatation of bladder neck and proximal urethra, and a pearl string-like configuration of urethra during the voiding phase. The clinical significance of these observations is presented.     

Four-corner bladder and urethral suspension for moderate cystocele

The classical approach to cystocele repair involves the approximation of lax pubocervical fascia through the anterior vaginal wall with narrowing of the bladder neck and proximal urethra by the Kelly-type plication. This procedure corrects the prolapse but when performed for the treatment of incontinence it has a high failure rate because the bladder neck and urethra are not placed into a high, supported, nonobstructed retropubic position. Furthermore, due to elevation of the bladder base without simultaneous elevation of the bladder neck and urethra, de novo stress urinary incontinence may occur. We developed a transvaginal needle suspension operation for the bladder and urethra that repairs anterior vaginal wall prolapse with excellent support of the bladder base and repositions the bladder neck in the high retropubic position, all during a simple and rapid operation that is tolerated well by the patient.     

人工反射弧重建膀胱功能动物模型的建立

目的 :建立犬“膝腱 脊髓 膀胱”反射弧重建膀胱功能的动物模型 ,作为实验研究人工膀胱反射弧的基础。方法 :家犬 5条 ,行硬膜外L5 S2前根交叉吻接 ,饲养 1年后刺激反射弧并记录膀胱压和尿道压变化。结果 :5只家犬“膝腱 脊髓 膀胱”反射弧均成功建立 ,刺激反射弧时膀胱压和尿道压都有升高。结论 :通过硬膜外L5 S2前根交叉吻接可以更有效地建立人工反射弧重建膀胱功能的动物实验模型。     

Case report: traumatic loss of the entire urethra and bladder neck in a girl--reconstruction by modified Flocks bladder tube.

Complete loss of the urethra and bladder neck secondary to pelvic fracture in a female patient is rare. We report a case of pelvic fracture resulting from a traffic collision leading to complete loss of the urethra including the bladder neck in an adolescent girl. A new urethra was reconstructed from a modified Flocks bladder tube and wrapped with omentum. At 2 years follow-up, the patient is fully continent and voiding satisfactorily. The problems of female urethral reconstruction are discussed.     

Complete duplication of the bladder and urethra.

We report a case of complete duplication of the bladder and urethra. The condition was asymptomatic and was associated with congenital dislocation of the right hip. Excision of the dorsal urethra and bladder, and correction of the chordee were done.     

Comparative autonomic responses of the cat and rabbit bladder and urethra.

The cat and the rabbit have both been utilized extensively in the study of lower urinary tract function. Previous studies have demonstrated that although both the cat and rabbit bladder are approximately the same weight, the in-vitro cat bladder can generate over 6 times the intravesical pressure of the rabbit bladder. The current study was designed to compare the ability of the isolated bladder to generate pressure with the pressures required to maintain flow through the isolated urethra for both the cat and the rabbit. The results can be summarized as follows. 1) The cat bladder is visibly much thicker than the rabbit bladder, and in vitro cystometry demonstrates that it is far less compliant than the rabbit bladder. 2) Over 20 cm.H2O pressure is required to begin flow through the isolated cat urethra preparation, whereas 5 cm.H2O begins flow through the rabbit urethra. 3) Increasing the flow rate (up to 7-fold) through both the isolated cat and rabbit urethra increases intraurethral pressure only slightly. 4) Both the isolated cat and rabbit urethra respond strongly to field stimulation and alpha-adrenergic stimulation (relative to the opening pressure required to begin flow), but not to cholinergic stimulation. 5) Field stimulation following pre-stimulation by methoxamine induces a strong relaxation of the pre-stimulated cat urethra, but an additive contraction in the pre-stimulated rabbit urethra. These studies demonstrate that in order for the cat to empty its bladder, it must generate a comparatively high intravesical pressure, whereas the rabbit is required to generate a relatively low intravesical pressure.     

Reflex interaction between the proximal urethra and the bladder. A clinical experimental study

OBJECTIVE: Animal experiments have shown that the bladder-cooling reflex is activated by cold stimulation of the bladder and urethra, causing a reflex bladder contraction. In this clinical experimental study, the bladder reflex responses to distension and cooling of the bladder neck and the proximal urethra were investigated. MATERIAL AND METHODS: Twenty-one patients with overactive bladders and documented positive ice water tests were studied. RESULTS: Three patients (14%) responded with reflex bladder contraction by urethral infusion of ice water only, and another 4 patients responded to urethral distension with both warm and cold water. In 4 patients, bladder contraction was induced by a catheter pulling on the bladder neck. CONCLUSION: This study supports the existence of a cold-sensitive reflex system in the human urethra. However, in the experimental situation, both cold and tension-mediated reflexes were more difficult to evoke from the urethra than from the bladder.     

Urethral duplication and complete bladder exstrophy

Urethral duplication is a rare anomaly that has been classified into epispadiac, hypospadiac, spindle, Y-duplications and collateral varieties. We report a case of an accessory urethra associated with complete bladder exstrophy in which the accessory urethra was integrated into the epispadias repair. To our knowledge this is the first case reported of urethral duplication associated with bladder exstrophy.     

Variations in urethral and bladder pressure during stress episodes in healthy women

Pressure variations in the urethra and bladder during stress episodes and their time separations were investigated in 30 healthy female volunteers. The pressure was measured by means of a double microtip transducer catheter with the distal sensor in the bladder and the proximal sensor at the bladder neck, the mid-urethra and the distal urethra. In advance of the pressure spike during cough a pressure rise was demonstrated in the bladder and at all 3 sites of measurement in the urethra. The urethral pressure increments preceding and following the pressure spike were statistically significantly higher in the mid-urethra than the corresponding bladder pressures. This active urethral pressure generation in the mid-urethra and distal urethra was initiated 200 ms before the bladder pressure began to rise. The pressure in the urethral high pressure zone was higher than the bladder pressure in all cases. Passive pressure transmission to the urethral high pressure zone can take place only insignificantly due to a continuous higher pressure inside the urethra than in the bladder and due to the location of the high pressure zone in the demarcation of the abdominal cavity. It was concluded that the urethral pressure rise in the high pressure zone during stress episodes is mainly generated actively by intra- and/or peri-urethral structures.     

Acupuncture needle in bladder

Self-introduction of various objects through the urethra into the bladder are too numerous to list. This is believed to be the first case of an acupuncture needle self-introduced into the bladder.     

Complete loss of female urethra & bladder floor

A search of available literature shows but 7 reported cases of complete destruction of urethra. None of these was accompanied by complete rupture of bladder floor. In only 4 are details available and the results obtained were completely satisfactory in only 1 of these. In this one the bladder floor was present and could be used for turning a flap forward in the building of a new urethra.To this list is added an eighth case in which the entire urethra and bladder floor have sloughed out. The repair was accomplished by free mobilization of the side walls and careful postoperative management. The result was perfect, both anatomically and functionally.     

Reconstruction of the urethra in women using a bladder flap

Three patients have been successfully operated with bladder flap procedures for severe functional impairment of the urethra. In two cases total urethral reconstruction was established with a rotary flap (= inverse Boari flap). The third case with recurrent incontinence and instable pelvis was cured by lengthening the urethra analogous the Leadbetter technique. Using a rotary bladder flap tube the whole urethra can be reconstructed. Continence is achieved without suspension procedure of the urethrovesical junction. The neomeatus urethrae internus should be placed as low as possible without injury to the bladder plate. Care must be taken to the blood supply because of the risk of flap necrosis. In case of good blood supply the one-stage urethral reconstruction is recommended.     

Long-term followup of patients after redo bladder neck reconstruction for bladder exstrophy complex

PURPOSE: The aim of this study was to determine whether redo bladder neck reconstruction is effective in achieving continence after a failed bladder neck reconstruction procedure. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients with bladder exstrophy who had undergone redo bladder neck reconstruction. There were 30 patients in the study, including 20 boys and 10 girls. Mean patient age at redo bladder neck reconstruction was 9.3 years (range 3.2 to 15.5). The patients were divided into 3 groups on the basis of the preoperative pattern of incontinence--incomplete wetters, complete wetters and those on continuous suprapubic drainage. Of the patients 15 already had undergone bladder augmentation, 12 had undergone a Mitrofanoff procedure and 12 had been treated with bulking agents injected in the bladder neck in an attempt to achieve continence. Four patients had undergone more than 1 bladder neck procedure. The patients were investigated with a combination of noninvasive urodynamics, cystoscopy, cystogram and ultrasound. All patients underwent Mitchell's modification of Young-Dees-Leadbetter bladder neck reconstruction. Additional procedures performed included augmentation cystoplasty and Mitrofanoff formation. RESULTS: Mean followup was 6.9 years (range 1.2 to 15.5). Postoperatively 28 patients were using clean intermittent catheterization to empty the bladder (5 per urethra, 23 via Mitrofanoff). Two patients remained on continuous suprapubic catheter drainage. A total of 18 patients (60%) were dry postoperatively (80% of girls and 50% of boys). Among dry patients only 3 were performing clean intermittent catheterization per urethra and 15 via a Mitrofanoff channel. No patient was able to void per urethra without the need for clean intermittent catheterization. The 2 patients on continuous suprapubic catheter drainage continued to remain so. At night only 50% of the patients were dry (5 on free drainage, 4 on clean intermittent catheterization, 6 not on any drainage). Those patients who did not respond satisfactorily to redo bladder neck reconstruction underwent subsequent additional procedures, which included injection of bulking agents (3 patients), insertion of an artificial urinary sphincter (1), Mitrofanoff formation (2) and bladder augmentation plus Mitrofanoff channel (1). Postoperative complications included difficulty with clean intermittent catheterization (8 patients), perivesical leak (1), recurrent epididymo-orchitis (1), upper urinary tract dilatation (2) and incisional hernia (1). Bladder neck closure was being considered in 5 patients. CONCLUSIONS: In our experience redo bladder neck reconstruction cannot achieve continence with volitional voiding per urethra. Although redo bladder neck reconstruction can render a significant number of patients dry, it is only effective if performed in conjunction with augmentation. Failure of the initial bladder neck reconstruction may be a reflection of a bladder that is of inadequate capacity and/or compliance. Therefore, bladder augmentation should be considered in all patients requiring redo bladder neck reconstruction. Bladder neck closure may be a better alternative to redo bladder neck reconstruction.     

女性早期尿道癌膀胱黏膜尿道重建术的探讨(会议征文选登)

目的:探讨应用膀胱黏膜重建女性尿道治疗女性尿道肉阜早期癌变的疗效。方法:对10例女性尿道肉阜早期癌变患者行一期膀胱黏膜尿道重建术,并作术前、术后6个月及术后1年最大尿流率测定。结果:10例均一期成形,术后随访1-9年,排尿正常,无肿瘤复发,无尿失禁及其他并发症,术前、术后6个月及术后1年最大尿流率测定差异有统计学意义(P(0.05)。结论:对于女性尿道肉阜早期癌变及早期原发性女性尿道癌患者,应用膀胱黏膜尿道一期重建术是可行的治疗方法,具有简单、安全、有效、并发症少等优点。     

运用计算机3dsMax技术构建男性膀胱尿道三维静态数学模型

目的：利用膀胱尿道CT影像材料通过计算机采集分析信息并利用软件3dsMax构建男性膀胱尿道三维数学模型。方法：采集24例成人男性膀胱尿道CT影像图片。通过DICOM浏览器扫描CT图像膀胱壁及男性尿道及副性腺与周围组织结构密度，运用计算机3dsMax软件构建男性膀胱的三维数学模型。结果：使用3dsMax计算机技术构建的3D男性膀胱、尿道、前列腺模型具有全方位，全视觉的特点．能够任意对不同的剖面进行分割，是用于教学及科研较好的数学模型。结论：计算机绘制三维匝建技术所构建的三维数学模型，能够进行男性膀胱尿道数字化。     

女性膀胱流出道梗阻的影像尿动力学检查特点分析

目的 探讨女性膀胱出口梗阻(BOO)患者影像尿动力学检查特点及意义.方法 女性BOO患者42例,根据梗阻部位分为膀胱颈梗阻(7例)、中段尿道梗阻(13例)、远端尿道梗阻(15例)、尿道外口梗阻(3例)、盆腔器官重度脱垂(4例)5组.患者术前均行影像尿动力学检查,比较5组病例Qmax、最大膀胱容量、Pdet atQmax、残余尿、逼尿肌无抑制收缩、双侧肾积水等指标.结果 42例患者中以尿频、尿急等储尿症状为主者17例(40.5%),以排尿困难等为主者4例(9.5%),混合症状者21例(50.0%).42例Qmax(10.9±5.6)ml/s、最大膀胱容量(253±140.7)ml、Pdet atQmax(53.3±25.7)cm H2O、残余尿量(76.2±70.3)ml,逼尿肌无抑制收缩者21例(50.0%);5组患者比较:最大膀胱容量差异无统计学意义;膀胱颈梗阻组Pdet atQmax最高、残余尿量最多、Qmax最低、肾积水比例最高,与其他各组比较差异有统计学意义(P<0.05);逼尿肌无抑制收缩在外括约肌部梗阻患者中10例(76.9%),与其他各组比较差异有统计学意义(P<0.05).结论 影像尿动力学检查能有效评估女性BOO下尿路功能,提示梗阻部位并指导临床治疗.女性BOO患者中膀胱颈梗阻程度是影响上尿路损害的主要因素.     

Transvaginal needle bladder neck suspension

Like the transabdominal bladder neck suspension, the aim of the transvaginal needle suspension of the bladder neck is to suspend the bladder neck and urethra in a fixed retropubic position. Because the transvaginal technique does not require the splitting of the abdominal wall fascia, postoperative discomfort and convalescence may be lessened. Different techniques of transvaginal needle bladder neck suspension, including suspension of the bladder neck with a fascial sling, are discussed in detail.     

Are biopsies from the prostatic urethra useful in patients with superficial bladder carcinoma?

Fifty male patients entered a Mitomycin C trial for superficial bladder cancer and biopsies in the prostatic urethra were taken with a cold cup biopsy forceps. In one patient this procedure failed. In 21 of 49 patients no abnormalities were detected but in the remaining 28 patients (57.1%) histological changes were found in the prostatic urethra. In 13 of these patients (26.5%) the changes were either carcinoma in situ (CIS) or superficial bladder carcinoma. Carcinoma in situ in the prostatic urethra was found in nine patients (18%) and in all but one it was combined with CIS in the bladder. These results indicate that biopsies from the prostatic urethra must be taken routinely in order to plan adequate therapy.     

Effects of vasoactive intestinal polypeptide on isolated urethral and urinary bladder smooth muscle from rabbit and man

Vasoactive intestinal polypeptide concentration-dependently inhibited the contractant responses of isolated preparations of the female rabbit bladder and urethra induced by electrical field stimulation and exogenous application of acetylcholine (bladder) and noradrenaline (urethra). The inhibition of alpha-adrenoceptor and muscarinic cholinoceptor-mediated activity in the urethra and bladder amounted to 50 to 90 per cent of induced contractions. The nonadrenergic noncholinergic contraction induced by electrical field stimulation in the urethra was reduced slightly, whereas corresponding response in the bladder was more sensitive. The maximum inhibition of both the electrically induced responses and contractions induced by exogenous noradrenaline and acetylcholine was of comparable size in the urethra and the bladder. The effects of vasoactive intestinal polypeptide seemed to be exerted postjunctionally since no significant influence of the peptide was seen on the release of 3H-noradrenaline from adrenergic nerve endings in the urethra. The effects of vasoactive intestinal polypeptide in human urethral and bladder preparations were less consistent. The noradrenaline-induced contraction in urethral preparations was inhibited by 29 +/- 9 per cent (no. = 22). The effects on electrically induced contractions in the urethra, and on responses to acetylcholine and electrical field stimulation in the bladder, were small and inconsistent. It is concluded that vasoactive intestinal polypeptide may be of importance for regulation of lower urinary tract smooth muscle activity in the rabbit. It cannot be excluded that the peptide has a modulatory role in neurotransmission in human urethral muscle. However, the present results do not support the view of vasoactive intestinal polypeptide as an inhibitor of contraction in human detrusor.     

The structure and innervation of smooth muscle in the wall of the bladder neck and proximal urethra.

Neurohistochemical and electron microscopic techniques have been employed to compare the structure and autonomic innervation of the bladder detrusor with that of the bladder neck and urethra in male and female cats, rats and guinea-pigs. In all specimens the structure and arrangement of smooth muscle in the detrusor was different from that in the bladder neck and proximal urethra. In male specimens this circular smooth muscle extended into the proximal urethra as far as the entrance of the ejaculatory ducts. A similar muscle coat was less well developed in the female but could be identified along the length of the urethra. Differences in the distribution of autonomic nerves have also been demonstrated. Presumptive cholinergic nerves were frequently encountered amongst the smooth muscle cells of the detrusor whilst noradrenergic nerves were relatively sparse. In contrast, muscle in the bladder neck and urethra was richly innervated by both types of autonomic nerve. In the male these findings are considered to provide support for the concept of a sphincteric mechanism which prevents retrograde ejaculation. In both sexes the possible functional role of the autonomic innervation of the bladder neck and proximal urethra during micturition has also been discussed.