INTERMITTENT CATHETERIZATION WITH A PRELUBRICATED CATHETER IN SPINAL CORD INJURED PATIENTS: A PROSPECTIVE RANDOMIZED CROSSOVER STUDY

PURPOSE: We compared the safety and patient acceptance of a conventional Nélaton and a prelubricated nonhydrophilic catheter in 18 spinal cord injured patients on intermittent catheterization. MATERIALS AND METHODS: In a prospective crossover study each catheter was used for 7 weeks and the initial course was randomized. Urinalysis and urine culture were performed at 2, 4 and 7 weeks. Urethral trauma was evaluated by urethral cell count on the surface of each catheter used on the last day of each study period. Patient satisfaction was assessed at the end of the study by a questionnaire using multiple visual analog scales. RESULTS: Urinary tract infection was identified in 12 and 4 patients on a Nélaton and a prelubricated nonhydrophilic catheter (p = 0.03), while asymptomatic bacteruria was identified in 18 and 8 (p = 0.0244), respectively. The mean urethral cell count plus or minus standard deviation on the catheter surface was 6.7 +/- 2.8 x 10(4) and 15.1 +/- 8.9 x 10(4) for the prelubricated nonhydrophilic and the Néelaton catheter, respectively (p = 0.01). The prelubricated nonhydrophilic catheter resulted in a better mean satisfaction score than the Nélaton catheter (2.33 +/- 1.06 versus 4.72 +/- 2.13, p = 0.022). Urethral bleeding was reported in 2 patients during the study period while using the Nélaton catheter. CONCLUSIONS: The prelubricated nonhydrophilic catheter is a safe, effective and comfortable option in spinal cord injured patients on intermittent self-catheterization.     

BLADDER LEAK POINT PRESSURE: THE MEASURE FOR SPHINCTEROTOMY SUCCESS IN SPINAL CORD INJURED PATIENTS WITH EXTERNAL DETRUSOR-SPHINCTER DYSSYNERGIA

Purpose

Transurethral resection of the external sphincter in patients with spinal cord injury and detrusor-external sphincter dyssynergia has high failure and reoperation rates. Retrospectively we examined elevated bladder leak point pressure after transurethral resection of the external sphincter as an indicator of failure.

Materials and Methods

A total of 55 spinal cord injury patients (mean age 50 years) underwent 1 or more sphincter resections, most recently a mean of 11 years ago. We reviewed the most recent urodynamic studies for bladder leak point pressure, bladder compliance and persisting external detrusor-sphincter dyssynergia. Each patient was assessed for the presence of an indwelling catheter, upper tract damage, stones, bacteriuria, autonomic dysreflexia and vesicoureteral reflux. The incidence of each of these urodynamic and clinical parameters among patients with bladder leak point pressure less than 40 cm. water was compared to the incidence among those with bladder leak point pressure greater than 40 cm. water.

Results

Patients with bladder leak point pressure greater than 40 cm. water had a significantly higher incidence of upper tract damage (p = 0.021) and persisting external detrusor-sphincter dyssynergia (p = 0.00008). The incidence of an indwelling catheter was no different between patients with bladder leak point pressure less than and greater than 40 cm. water.

Conclusions

Bladder leak point pressure greater than 40 cm. water is a valid indicator of failure of transurethral resection of the external sphincter since there is a significantly higher incidence of upper tract damage and persisting external detrusor-sphincter dyssynergia in these patients. Patients with favorable urodynamic parameters after transurethral resection of the external sphincter but with indwelling catheters were poorly selected for this procedure. Furthermore, those without an indwelling catheter after transurethral resection of the external sphincter may still have adverse urodynamic parameters and are at significant risk for upper tract damage.     

HOLMIUM LASER VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: A RANDOMIZED PROSPECTIVE TRIAL WITH 1-YEAR FOLLOWUP

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.     

PREDICTORS OF NECROSPERMIA IN MEN WITH SPINAL CORD INJURY

Purpose

We identify predictors of the lowest yield of dead sperm in ejaculates of men with spinal cord injury.

Materials and Methods

The percentages of dead immotile sperm and dead total sperm were compared in 141 spinal cord injured and 52 normal men. Predictors of necrospermia investigated in spinal cord injured men included specimen collection by vibratory stimulation versus electroejaculation, residence of sperm in antegrade versus retrograde specimens and level of injury.

Results

Spinal cord injured subjects had a significantly higher percentage of dead sperm in the immotile fraction and total specimen than control subjects. The percentage of dead sperm was lower in antegrade versus retrograde specimens and in specimens produced by vibratory stimulation versus electroejaculation. There was no difference in the percentage of dead sperm by level of injury.

Conclusions

Of the parameters evaluated only method and type of specimen collection were predictive of the degree of necrospermia in men with spinal cord injury. Level of injury was not predictive. The ratio of dead-to-live immotile sperm in spinal cord injured men was double that in normal men, indicating a pathological mechanism for sperm cell death.     

SERUM AND SEMEN PROSTATE SPECIFIC ANTIGEN CONCENTRATIONS ARE DIFFERENT IN YOUNG SPINAL CORD INJURED MEN COMPARED TO NORMAL CONTROLS

PURPOSE: Recent investigations have indicated that factors within the seminal plasma may contribute to the condition of low sperm motility in men with spinal cord injury. To determine whether the prostate gland functions normally in these men we chose prostate specific antigen (PSA) as a marker of prostatic function, and compared serum and semen concentrations in spinal cord injured and healthy noninjured men. MATERIALS AND METHODS: The study included 21 spinal cord injured men (mean age 33.3+/-1.2 years) and 22 noninjured normal men (mean age 30.3+/-1.5 years). Blood was obtained from subjects following at least 24 hours of abstinence from ejaculation and serum PSA was determined by modified enzyme immunoassay. Antegrade ejaculates from all subjects were frozen to -80 C, exactly 15 minutes after collection. Seminal plasma PSA was determined using Hybritech Tandem MP assay. RESULTS: Mean serum PSA concentration was 1.20+/-0.19 ng./ml. in spinal cord injured and 0.69+/-0.07 ng./ml. in noninjured men (p<0.02). Mean seminal plasma PSA concentration was 0.59+/-0.11 mg./ml. in spinal cord injured and 1.29+/-0.15 mg./ml. in noninjured men (p<0.001). CONCLUSIONS: Our findings of elevated serum and decreased seminal plasma PSA concentrations indicate that prostatic secretory dysfunction is present in men with spinal cord injury.     

神经生长因子保护受伤脊髓组织的实验研究

为了解神经生长因子（ＮＧＦ）对损伤的脊髓组织的作用，采用Ａｌｅｎ氏ＷＤ装置，以１０ｇ冲击棒自２．５ｃｍ高度下落撞击ＳＤ大鼠Ｔ８脊髓，并于蛛网膜下腔内置入导管。术后，实验组经导管注入ＮＧＦ溶液；对照组则注入生理盐水。术后４，８及２４ｈ，取脊髓损伤段标本，分别经干湿法、原子吸收光谱法测量水、钙含量。结果发现：损伤脊髓段组织钙含量明显增高，组织水肿严重；脊髓损伤后，应用ＮＧＦ可显著改善这些变化。这一实验结果证实ＮＧＦ对受伤的脊髓有明显的保护作用，其保护作用与稳定钙离子水平有关。     

THE ROLE OF OXYBUTYNIN IN SPINAL CORD INJURED PATIENTS WITH INDWELLING CATHETERS

Purpose

The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis.

Materials and Methods

A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl.

Results

The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine.

Conclusions

It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified.     

A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING SUPRAPUBIC WITH URETHRAL CATHETERIZATION IN RECTAL SURGERY

Background : Bladder drainage is necessary for several days following rectal surgery. Urethral catheterization has long been known to be associated with significant morbidity. Therefore a prospective randomized trial was performed to determine if this morbidity could be decreased by suprapubic catheterization. Methods : One hundred and thirty-seven patients undergoing rectal surgery were prospectively randomized to either suprapubic or urethral catheterization. Results : After exclusions, 108 patients were analysed. Of the 49 patients with suprapubic catheters there was 14% morbidity, and of the 59 patients with urethral catheters there was 32% morbidity. Significant bacteriuria was halved with suprapubic catheterization. Patient acceptability of suprapubic catheterization was high, and there was no increased morbidity in any of the areas studied. Conclusions : This study suggests that suprapubic catheterization has advantages over urethral catheterization with decreased bacteriuria, and greater patient acceptability. However, the significance of decreased bacteriuria is not clear and therefore we can only say suprapubic catheter drainage is comparable to urethral catheter drainage.     

脊柱脊髓损伤的修复重建研究进展

目的阐述脊柱、脊髓损伤最新研究及治疗进展.方法广泛查阅文献,并结合研究及临床经验,总结近几年脊柱、脊髓损伤的研究动向及临床应用结果.结果后路寰枢椎固定技术由既往的侧块关节直接螺钉内固定术发展到今天较为常用的寰枢椎椎弓根或侧块螺钉相组合的钉板、钉棒内固定技术.经口咽入路寰枢椎复位钢板固定术能较好解决难复性环枢椎脱位的问题.胸腰椎骨折的手术入路、固定节段、融合方式等目前仍没有统一的标准,只要条件允许,前路和后路手术均能达到有效减压和稳定重建的目的.单节段骨折固定术较既往的跨节段固定术有一定优势.内窥镜辅助下或影像介导下的脊柱诊疗技术在我国逐渐开展.对治疗顽固疼痛性骨质疏松性压缩骨折患者,国内紧跟国外潮流及时开展经皮椎体成形术和后凸成形术,以重建椎体高度,修复椎体稳定性,改善症状,提高生活质量.相关的基础和临床研究使人们对急性脊髓损伤的药物治疗有了重新认识,而生物学治疗方法为神经的修复再生提供了新的思路,其中细胞移植和基因疗法是极有前景的治疗策略.结论随着脊柱外科的飞速发展,脊柱脊髓损伤的修复重建取得了长足的进步.     

ENTERAL VERSUS PARENTERAL NUTRITION AFTER OESOPHAGOGASTRIC SURGERY: A PROSPECTIVE RANDOMIZED COMPARISON

Background: There appears to be an emerging consensus that early postoperative nutritional support benefits the high-risk patient by decreasing septic morbidity, maintaining immunocompetence and improving wound healing. Enteral nutrition via a feeding jejunostomy has been associated with serious complications, with a reported mortality rate as high as 10%. while total parenteral nutrition has also been associated with a wide variety of complications. Methods: Ninety-seven patients undergoing oesophagectomy or gastrectomy underwent pre-operative nutritional assessment and were randomized to receive either total parenteral nutrition (47 patients) or enteral nutrition (50 patients). Results: There was no significant difference in the number of catheter-related complications between the two groups, but 9 (45%) patients in the total parenteral nutrition group had major morbidity (potentially fatal in two patients) requiring active intervention. Conclusions: This study demonstrates enteral nutrition to be safe and associated with mainly reversible minor complications. It is probable that immediate postoperative enteral feeding conserves the gut's integrity. Whether this leads to a reduction in postoperative septic complications has not been demonstrated by this study although there appears to be a trend in this direction, supporting the concept of enteral feeding as ‘primary therapy’. This can be safely, simply and economically achieved using a feeding jejunostomy placed at the time of surgery.     

EARLY FEEDING AFTER ELECTIVE OPEN COLORECTAL RESECTIONS: A PROSPECTIVE RANDOMIZED TRIAL

Background : A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. Methods : Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24–48 h. Results : There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. Conclusion : Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.     

INTRARECTAL LIDOCAINE DURING TRANSRECTAL PROSTATE BIOPSY: RESULTS OF A PROSPECTIVE DOUBLE-BLIND RANDOMIZED TRIAL

PURPOSE: Recent reports have indicated the benefit of anesthesia during prostate biopsy. To assess this finding objectively we performed a prospective randomized double-blind study to compare patient pain with and without local anesthesia during transrectal ultrasound guided prostate biopsies. MATERIALS AND METHODS: Between August 2000 and March 2001, 108 men undergoing transrectal ultrasound guided biopsy of the prostate were randomized in double-blind fashion to receive intrarectal 2% lidocaine gel or intrarectal lubricant alone. No patient received pre-procedure narcotics or sedation. Pain associated with biopsy was determined using a horizontal linear visual analog pain scale. Pain scores in the 2 treatment groups were compared and possible predictors of increased pain were examined. RESULTS: The 2 groups were similar in demographic characteristics. There was no significant difference in pain score in the 2% lidocaine and lubricant alone groups (28.3 versus 28.9 mm., p = 0.88). Previous biopsy, time since previous biopsy, physician, number of biopsies and prostate volume did not correlate with pain score, while age correlated negatively with the score (r = -0.27, p = 0.005). A single complication involving a vasovagal episode resolved spontaneously. CONCLUSIONS: Intrarectal lidocaine gel provides no significant therapeutic or analgesic benefit compared with lubricant alone for transrectal ultrasound guided biopsy of the prostate. In younger patients more discomfort is associated with this procedure.     

COMBINED ORCHIECTOMY AND EXTERNAL RADIOTHERAPY VERSUS RADIOTHERAPY ALONE FOR NONMETASTATIC PROSTATE CANCER WITH OR WITHOUT PELVIC LYMPH NODE INVOLVEMENT: A PROSPECTIVE RANDOMIZED STUDY

Purpose

We compare the combination of orchiectomy and radiotherapy to radiotherapy alone as treatment for pelvic confined prostate cancer, that is T1-4, pN0-3, M0 (TNM classification).

Materials and Methods

In this prospective study 91 patients with clinically localized prostate cancer were, after surgical lymph node staging, randomized to receive definitive external beam radiotherapy (46) or combined orchiectomy and radiotherapy (45). Patients treated with radiotherapy alone had androgen ablation at clinical disease progression. The effects on progression-free, disease specific and overall survival rates were calculated.

Results

After a median followup of 9.3 years (range 6.0 to 11.4) clinical progression was seen in 61% of the radiotherapy only patients (group 1) and in 31% of the combined treatment patients (group 2) (p = 0.005). The mortality was 61 and 38% (p = 0.02), and cause specific mortality was 44 and 27%, respectively (p = 0.06), in groups 1 and 2. The differences in favor of combined treatment were mainly caused by lymph node positive tumors. For node negative tumors there was no significant difference in survival rates.

Conclusions

The progression-free, disease specific and overall survival rates for patients with prostate cancer and pelvic lymph node involvement are significantly better after combined androgen ablation and radiotherapy than after radiotherapy alone. These results strongly suggest that early androgen deprivation is better than deferred endocrine treatment for these patients.     

成年大鼠压迫性脊髓损伤后损伤区神经干细胞的分离培养实验研究

目的 研究脊髓损伤后损伤反应性巢蛋白(nestin)和胶质酸性纤维蛋白(glial fibrillary acid protein, GFAP)阳性共存(nestin+/GFAP+)细胞的分裂、增殖和分化能力,以探讨其是否具有神经干细胞(neural stem cells,NSCs)特性. 方法 8周龄雄性SD大鼠12只,体重200～250 g,随机分为正常对照组和模型组(n=6).模型组利用动脉瘤夹压迫法建立成年大鼠脊髓损伤动物模型,正常对照组不作任何处理.造模后5 d,两组分别取大鼠Ts脊髓节段,分离中央管周围室管膜区以外的脊髓灰质和白质,制成单细胞悬液,用无血清NSCs培养基进行培养,并用含血清NSCs培养基进行诱导分化,利用免疫荧光化学和流式细胞仪观察细胞类型及分裂、分化、增殖能力. 结果 模型组培养后3～7 d,单细胞悬液中有大量高度表达的nestin+/GFAP+共存细胞,细胞计数为5.15±0.71;对照组为1.12±0.38;两组比较差异有统计学意义(P<0.01).细胞周期结果 示,模型组S期细胞比例(15.49%±3.04%)及增殖指数(15.88%±2.56%)均明显高于对照组(5.84%±0.28%,6.47%±0.61%),两组比较差异有统计学意义(P<0.01).模型组原代细胞逐渐形成边缘光滑、中心膨隆有立体感的小克隆球,nestin免疫荧光染色呈强阳性,多次传代后获得大量细胞克隆球.对照组单细胞悬液原代及传代培养均未见明显克隆球生长.免疫染色结果 示模型组克隆球诱导分化约5 d,细胞球中含有大量半乳糖脑苷脂(galactocerebroside,GaLC)-nestin免疫染色阳性细胞;5～7 d,大量β-微管蛋白Ⅲ(β-tubulin Ⅲ)-nestin和GFAP免疫染色阳性细胞;7～14 d出现GaLC阳性少突胶质细胞、β-tubulin Ⅲ神经元和GFAP染色阳性的胞体及细胞突起. 结论 成年大鼠压迫性脊髓损伤后,剔除中央管周围室管膜区脊髓白质与灰质分离而得的nestin+/GFAP+细胞,具有自我更新能力和多分化潜能,是中枢神经系统的NSCs.     

AN ANALYSIS OF 653 TRIALS OF PENILE VIBRATORY STIMULATION IN MEN WITH SPINAL CORD INJURY

Purpose

We evaluated ejaculatory response and semen quality in 653 trials of penile vibratory stimulation in 211 men with spinal cord injury, and compared results with low versus high amplitude vibratory stimulation.

Materials and Methods

Low and/or high amplitude penile vibratory stimulation was performed 1 to 27 times in each patient, and antegrade and retrograde specimens of those who ejaculated were analyzed.

Results

Significantly more patients ejaculated using high (54.5%) versus low (39.9%) amplitude stimulation. Using either amplitude the ejaculatory success rate was highest in men with injuries at C3 to C7, followed by T1 to T5, T6 to T10 and T11 to L3. While high amplitude stimulation increased the ejaculatory success rate in each group, the highest rate occurred in men with injuries at C3 to C7 (65.6%). Ejaculation was reliable, since most men who ejaculated did so during 100% of the trials and within 2 minutes of stimulation onset. Symptoms of autonomic dysreflexia were safely managed with nifedipine. All patients who ejaculated produced antegrade specimens. With the exception of ejaculate volume, which was significantly higher with high versus low amplitude stimulation, semen parameters were similar using both vibrator amplitudes.

Conclusions

Ejaculatory success is better while semen quality is similar using high versus low amplitude penile vibratory stimulation in men with spinal cord injury. This method may be considered first line treatment for anejaculation in men with spinal cord injury. This method may be relative effectiveness, and relatively low investment of time and money.     

COLLAGEN INJECTION FOR INTRINSIC SPHINCTERIC DEFICIENCY IN MEN: A REASONABLE OPTION IN SELECTED PATIENTS

Purpose

We evaluate transurethral collagen injection as a minimally invasive option in treating stress urinary incontinence in men and identify the prognostic factors for success or failure.

Materials and Methods

Transurethral collagen was injected in 35 men with grades III (22) and II (13) incontinence.

Results

Of the patients 7 became dry (20%), 11 improved (31.4%) and 17 were considered failures (48.6%). Abdominal leak point pressure increased and the number of pads needed decreased. In the failed group 4 patients had a history of pelvic irradiation, 5 urethral stricture disease and 3 bladder instability before injection. There was 1 case of temporary urinary retention as a complication.

Conclusions

Transurethral collagen injection for male stress urinary incontinence is a reasonable option in select patients.