Continence after total bladder replacement: urodynamic analysis of the ileal neobladder

Since April 1986 we have carried out 103 bladder substitutions with the ileal neobladder; 91 of these were performed after radical cystectomy in males (group 1) and 12 after subtotal bladder resection (group 2); 55 patients in group 1 and 8 in group 2 were followed up by long-term urodynamic investigations and by a questionnaire concerning micturition patterns and continence at home 3 months post-operatively. The maximum bladder capacity was approximately 770 ml with an absolute intravesical pressure of 23 to 30 cm H2O. Intravesical pressure waves with a mean amplitude of 20 cm H2O were found in 38% of patients in group 1 and 25% in group 2; 61% of these patients were asymptomatic. The results showed that 85% of patients were continent by day and by night. We attribute this to our operative technique: the ileal loop is folded 4 times in a "W" or "M" shape to achieve complete detubularisation of the bowel and the external urethral sphincter is carefully preserved. Altogether, these data show the ileal neobladder technique to be a reliable and safe method of bladder substitution.     

The impact of formal education and training on urodynamic practice in the United Kingdom: a survey

AIM: A previous survey of personnel performing urodynamics had shown that half of the respondents thought that their training had been inadequate. In order to address this the outcome of a 4-day practical course for teaching urodynamics, which has been running since 1995 at the Bristol Urological Institute, was reviewed. We were not aware of any published studies that have assessed the impact of formal urodynamic training on clinical practice. With this in mind we set out to determine whether the education and training we had given had changed urodynamic practice in the UK. METHODS: Postal questionnaires were sent out to 84 delegates who had attended the course over a 2-year period (2001-2003). Paired questionnaires were used to assess urodynamic practice before and after the course and also to establish whether their practice had changed as a direct result of attending the certificate course. RESULTS: The results suggested that 79% of those responders had changed their practice since completing the course. Significant changes to practice were observed in checking calibration, confidence in setting-up equipment, interpretation of urodynamic traces and ability to check the accuracy of the results. CONCLUSIONS: The results of this survey suggest that attendance at a recognised urodynamic training course has had an impact on clinical practice in the UK. Training and education raises the level of confidence and ability to perform and interpret urodynamic investigations, which has wide implications for the accuracy, reliability and consistency of urodynamic investigations performed by those without formal training.     

Continence after radical cystoprostatectomy and total bladder replacement: a urodynamic analysis.

Urodynamic evaluation was performed in 10 patients after radical cystoprostatectomy and continent urethral diversion with detubularized ileum and in 13 patients continent after radical prostatectomy. In both groups surgical techniques were modified to optimize preservation of the periurethral tissue at the prostatic apex. For the ileal neobladder group 9 patients (90%) were completely continent and 1 (10%) noticed moderate nocturnal incontinence. The urethral sphincteric mechanism was well preserved in these patients, with no significant difference between the 2 groups in mean functional urethral length (3.8 +/- 0.6 versus 3.6 +/- 0.8 cm., p = 0.55) or maximal urethral closure pressure (87 +/- 34 versus 74 +/- 20 cm. water, p = 0.26). Tubularization of the bladder or neobladder above the level of the external sphincter was noted in both groups. Continence after radical cystoprostatectomy with continent urethral diversion and after radical prostatectomy is dependent upon an intact urethral sphincteric mechanism as well as a compliant, low pressure reservoir, either bladder or a bladder substitute. Urinary incontinence after total bladder replacement with detubularized ileum can be minimized by preserving as much of the distal urethral sphincter as possible. This can be done by careful dissection of the prostatic apex, performed under direct vision, with an understanding of the anatomy of the urethral sphincter and its innervation.     

Meeting the standards for interhospital transfer of adults with severe head injury in the United Kingdom

We assessed the hourly occupancy of our intensive care and high dependency units over an 8-week period commencing on the day our high dependency unit opened. Using criteria established by the working group on 'Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units' published by the National Health Service Executive, we defined each patient daily as intensive care or high dependency status. Compared with hourly occupancy figures obtained before the high dependency unit opened, occupancy of the intensive care unit by high dependency patients has been shown to decrease significantly from 21.6% to 11.2%. Use of intensive care beds became more appropriate, their occupancy increasing significantly from 63.7% to 73.4%. A significant decrease in readmissions occurred, supporting the hypothesis that having high dependency beds reduces the number of patients discharged prematurely to the wards.     

Good urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow studies

This is the first report of the International Continence Society (ICS) on the development of comprehensive guidelines for Good Urodynamic Practice for the measurement, quality control, and documentation of urodynamic investigations in both clinical and research environments. This report focuses on the most common urodynamics examinations; uroflowmetry, pressure recording during filling cystometry, and combined pressure-flow studies. The basic aspects of good urodynamic practice are discussed and a strategy for urodynamic measurement, equipment set-up and configuration, signal testing, plausibility controls, pattern recognition, and artifact correction are proposed. The problems of data analysis are mentioned only when they are relevant in the judgment of data quality. In general, recommendations are made for one specific technique. This does not imply that this technique is the only one possible. Rather, it means that this technique is well-established, and gives good results when used with the suggested standards of good urodynamic practice.     

Meeting the standards for interhospital transfer of adults with severe head injury in the United Kingdom.

In December 1996, the Association of Anaesthetists of Great Britain and Ireland produced a series of recommendations outlining the safe conduct of interhospital transfers for patients with acute head injuries. We assessed the current ability of UK hospitals to implement these recommendations and opinions on the formation of transfer teams, using a postal questionnaire. This was sent to all Royal College of Anaesthetists tutors, 268 of whom replied (94% response rate). Of the hospitals surveyed, 208 received adult head-injury patients but did not have on-site neurosurgical facilities. In 171 (86.8%) of these hospitals, senior house officers could be expected to accompany the patient during subsequent transfer. The majority of hospitals (192, 92.3%) were able to monitor ECG, pulse oximetry and blood pressure during the journey, but only 97 (46.6%) had facilities to monitor end tidal carbon dioxide levels. As a result of the anaesthetist's involvement in the transfer, emergency operating could be delayed in 169 (81.3%) hospitals. One hundred and fifty-eight (76%) respondents thought that the formation of transfer teams to transport critically ill patients would have some merit. Hospitals are responding to the published guidelines, but improvements are still needed in levels of equipment and insurance provision, along with the identification of a designated consultant at each hospital with responsibility for transfers.