Sacral nerve stimulation for urinary dysfunction: the first year of the Scottish national service.

Sacral nerve stimulation (SNS) has become an established treatment option for patients with intractable detrusor overactivity and non-obstructive urinary retention. The Scottish Sacral Nerve Stimulation service was established in April 2010 to provide a service for the population of Scotland. We report our experience from the first year of this new national service. All patients referred for SNS from the inception of the service in April 2010 until the end of March 2011 were studied. During the one-year period, there were 50 referrals. Thirty-three percutaneous nerve evaluations, eight tined lead tests and 16 permanent implantation procedures were performed during this period. Morbidity was low and both incontinence and quality-of-life questionnaires demonstrated statistically significant improvements (International Consultation on Incontinence Questionnaire [ICIQ-SF], P = 0.005; Incontinence Impact Questionnaire [IIQ 7], P = 0.0007; Urogenital Distress Inventory [UDI 6], P = 0.0002). Referral pattern was skewed towards the west of Scotland with some health boards producing no referrals during the year. Results from the first year of the service have shown that it is a safe and efficient procedure with significant improvement in incontinence, voluntary voiding and quality-of-life parameters. The limitation of funding for permanent implants inevitably impacts on the role of the technique as a management option in these patients.

Intravesical botulinum toxin type A in chronic interstitial cystitis: results of a pilot study.

AIM: To assess the efficacy of intravesical botulinum toxin type A (BTX-A) in interstitial cystitis (IC). METHODS: Eleven patients with IC were injected with BTX-A. Primary outcome measures were: Bristol Female Lower Urinary Tract Symptom Score, Kings Health Questionnaire and 24-hour frequency-volume chart. They had urodynamics done before and six weeks after injection. Detrusor contractility was assessed using the modified PIP1 (projected isovolumetric detrusor pressure).

The use of the artificial urinary sphincter in the West of Scotland: a single centre 10-year experience.

BACKGROUND: The artificial urinary sphincter (AUS) has been used successfully to treat sphincter weakness incontinence in males over the past 30 years. Postoperative complications are well-recognised, but patient satisfaction remains high. METHODS: We performed a retrospective single centre study of all patients who had an artificial urinary sphincter inserted over a 10-year period. We assessed patient satisfaction and continence post operatively as well as complication rate and need for revision or replacement surgery. RESULTS: Thirty-eight male patients (mean age 57 years) and 1 female patient had an AMS 800 (American Medical systems) AUS inserted between 1995 and 2005. Five (13%) patients have required replacement surgery to date. Male patients were divided into two groups according to the aetiology of their incontinence: neuropathic (n = 11) and non-neuropathic (n = 27). Social continence was achieved in all patients. Three (11%) non-neuropathic patients developed complications. Revision surgery was undertaken in 4 (15%) of non-neuropathic patients and in 1 (9%) neuropathic patient. The mean lifespan of the AUS in patients who required further surgery is 6.6 years. CONCLUSION: For patients with severe sphincter weakness incontinence the AMS 800 AUS is a safe and reliable solution. Our results are comparable with previous published studies of larger patient numbers from dedicated reconstructive units.

HMFG-2 as a prognostic indicator in superficial bladder cancer.

A series of transitional cell carcinomas and mucosal biopsy specimens of bladder were stained immunohistochemically with the monoclonal antibody HMFG-2. Staining characteristics ranged from luminal staining in well differentiated, superficial lesions to staining of all cells in invasive carcinomas. Invasive tumour nests also stained strongly with the antibody. There was good correlation between the staining pattern and histological assessment of both tumours and mucosal biopsy specimens. Correlation with clinical course showed that it was also a good predictor of subsequent disease progression of superficial tumours. It is suggested that HMFG-2 staining is a sensitive indictor of malignant transformation and that it may have a role as an adjunct to conventional histological examination in the assessment of urothelial carcinomas.

Short-term cephradine prophylaxis in elective transurethral prostatectomy.

A prospective randomized trial was conducted to assess the value of short-term antibiotic prophylaxis in elective transurethral resection of the prostate. Two hundred patients were randomized to receive 1.5g cephradine intramuscularly preoperatively and 1g cephradine orally before removal of the urethral catheter or to receive no antibiotic prophylaxis. Fifty-eight patients were excluded because of occult neoplasm or protocol violation. There was no difference in time to removal of catheter, incidence of pyrexial episodes, length of hospital stay or minor complication rate between the two groups. We conclude that a short-term antibiotic regime is of no value in the elective patient with sterile urine.

Computerised triage in a prostate assessment clinic.

An MS Office package has been developed to score IPSS, take a patient history, compare flows with nomograms and decide on interim management. This is based on these scores, residual volume and laboratory results. A clearly formatted GP letter is produced. The patient uses a touch screen to answer questions on the IPSS and other medical history. These questions and responses are stored in Excel spread sheets. Clinic staff then enter results of flow studies, urinalysis, U&E and PSA. Excel Visual Basic creates a detailed printout for the notes and the MS Office mail merge facility creates a summary printout, which also serves as a letter to the GP. Excel allows embedding of formulae and program code to implement the rules for management. Based on these rules, the program either generates a request for an urgent appointment in the clinic or recommends the use of either an alpha blocker (if not contraindicated by medical history) or 5 alpha reductase inhibitors in the interim period before they are reviewed in clinic. A total of 139 patients have been seen and the computer decisions compared with those of a consultant urologist. Agreement was found in 106, disagreement in 33. However, 21 of the 33 involved computer oversensitivity to flow results. We do not anticipate difficulty improving this and are investigating using an artificial neural network. Of the other 12 patients, the urologist departed from the fixed rules for IPSS, creatinine, PSA and residual urine when only one variable was slightly abnormal. To conclude, this novel user-friendly system shows great potential in the management of prostate outpatients. Some tuning is needed, with particular respect to uroflow results.

The anatomy of the facial nerve in relation to CT/sialography of the parotid gland.

The technique of computed tomography with simultaneous parotid sialography allows for accurate localisation of tumours within the parotid gland. The relationship of these tumours to the facial nerve, which divides within the gland, is of surgical significance. A study of the course of the facial nerve through the parotid gland in the cadaver was therefore undertaken in order to identify relevant landmarks for the CT prediction of its relationship to those tumours. The heads of five cadavers were sectioned in the Frankfurt plane into 1 cm slices which were then X-rayed. Individual slices were examined and the course of the facial nerve was plotted on the X-ray plate of the same slice. It was found that the nerve could be represented on a CT scan by an arc of radius 8.5 mm, the centre of which is the most posterior point of the ramus of the mandible. The arc extends from directly lateral to directly posterior to that point. Pre-operative visualisation of parotid tumours by simultaneous CT scan and sialography in conjunction with an appreciation of the course of the facial nerve through the parotid gland may allow for more precise presurgical planning.

Transcutaneous electrical nerve stimulation following appendicectomy: the placebo effect.

A controlled trial was undertaken to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) with standard intramuscular opiate analgesia in the management of postoperative pain following appendicectomy. Consecutive patients undergoing emergency appendicectomy were randomised into control, sham TENS and active TENS groups. There was a significant decrease in pain severity and analgesic intake in both active and sham TENS groups when compared with the control group (P less than 0.01). No difference was demonstrated in pain severity between active and sham TENS groups but the active TENS group required slightly less analgesia. These results suggest that the major benefit of TENS in the postappendicectomy patient is due to its 'placebo effect' and its use in this situation cannot be recommended.

Complete resolution of a large seminal vesicle cyst--evidence for an obstructive aetiology.

Seminal vesicle cysts may arise from inflammation or obstruction of the seminal vesicle or from embryological remnants such as the müllerian duct. Surgical removal has been proposed as the treatment of choice. A 19-year-old boy presented with abdominal pain and constipation. Investigations revealed a 14-cm multiloculated cyst arising from the right seminal vesicle and a small stone lodged at the orifice of the ipsilateral ejaculatory duct. Following endoscopic removal of the stone the mass decreased in size considerably and 2 months later transrectal ultrasound and magnetic resonance imaging showed normal seminal vesicles and no evidence of the cyst. This case strongly supports an obstructive aetiology for this cyst and we would suggest that, in similar cases, full assessment of the ejaculatory apparatus should be carried out to exclude an obstructive cause before embarking on major surgery.

Co-oxidation of arachidonic acid and methimazole by prostaglandin endoperoxide synthetase.

The thiocarbamide methimazole stimulated O2 utilisation when added to reaction mixtures containing ram seminal vesicle microsomes (prostaglandin endoperoxide synthetase preparation) and arachidonic acid. This stimulation increased with increasing methimazole concentrations, as did the production of prostaglandin E. 2-[14C]Methimazole was co-oxidized to 1-methyl-2-[14C]imidazole.

Basement membranes in urothelial carcinoma.

Invasion of a bladder tumour involves the degradation and penetration of the subepithelial basement membrane. A retrospective study of 69 superficial and 15 invasive transitional cell carcinomas of bladder and a prospective study of 43 mucosal biopsies were performed in order to assess the usefulness of immunohistochemical staining of the basement membrane components, type IV collagen and laminin as prognostic indicators in superficial bladder cancer. There was a significant association between pT category and basement membrane staining. The incidence of progression of superficial tumours with patchy or absent basement membranes was significantly greater than those with complete basement membranes but there was no association with superficial recurrence. Biopsies of dysplastic epithelium had thickened and reduplicated basement membranes, possibly as a result of increased cell turnover. The results suggest that a balance exists between basement membrane production and degradation in early malignancy. This technique may be of value in the early identification of microinvasion and in the prediction of subsequent progression.

Comparison of patients' assessment of urinary flow strength with uroflowmetry.

OBJECTIVE: The objective of the study was to compare patients' self-assessment of urinary flow strength with uroflowmetry. METHODS: The study was set in the routine uroflow clinic of the urology department. All patients had symptoms of bladder outlet obstruction. They answered 2 questions and a multiple-choice pictorial representation of flow trajectory. Patients were encouraged to provide 3 flows with at least one volume over 150 ml. The maximum flow rate Qmax was compared with the subjective evaluations. RESULTS: Qmax was normally distributed. Answers to the questions did separate patients significantly (p < 0.001). However, overlap between groups was large; the group who answered that their flow was poor included many false positives. Pictorial assessment showed low correlation with Qmax, again with a high false-positive rate. CONCLUSION: Patients' self-assessment of strength of stream is unreliable as a measure of Qmax and therefore of obstruction. Resection of prostate on history alone is not recommended.

Complications of clam enterocystoplasty with particular reference to urinary tract infection.

A study was carried out on 112 patients who had undergone a clam procedure. Follow-up extended from 15 months to 8 years. The efficacy of the operation in achieving and maintaining continence in patients with instability and hyper-reflexia was confirmed (93% in the neuropathic group, 91% in the congenital instability group and 78% in the idiopathic group). Complications were common and included inability to void (requiring self-catheterisation), haematuria, mucus production and recurrent urinary tract infection. Complete bacteriological data were obtained on 80 patients; 30% were infected pre-operatively (all but 4 in the neuropathic group) but 66% had bacteriuria at the time of assessment after surgery. Subjectively, 17 patients (24%) who "never" got infected had bacteriuria, as did 29 (63%) of those who were "occasionally" infected. Objectively, 84% of patients on intermittent self-catheterisation (ISC) had positive cultures, but even in those voiding spontaneously bacteriuria was present in 60%. Careful follow-up of these patients is mandatory and a more rigorous approach to eradication of infection and subsequent prophylaxis has been instituted.

Immunohistochemical staining with monoclonal antibody 32-2B to desmosomal glycoprotein 1. Its role in the histological assessment of urothelial carcinomas.

A series of transitional cell carcinomas of bladder were stained immunohistochemically with the monoclonal antibody, 32-2B, to desmosomal glycoprotein 1. All of the sections showed positive staining with the antibody. Assessment of staining intensity, by 3 independent examiners, revealed a strong negative correlation between density of desmosomal staining and degree of invasion (P = 0.012). Nests of strongly staining cells were identified in several invasive tumours, possibly indicating early squamous differentiation. Invasive tumour cells in the subepithelial stroma also stained strongly with the antibody. Correlation with clinical course, however, revealed no significant association between desmosomal staining and the incidence of recurrence or progression. It is suggested that staining with this antibody may be of value in detecting both stromal invasion and early squamous differentiation of transitional cell carcinomas. Both this and previous studies emphasise the value of this antibody as an epithelial marker in neoplasia.

Morbidity following cystoscopy: comparison of flexible and rigid techniques.

Recent reports on the value of local anaesthetic flexible cystoscopy have emphasised excellent tolerance and preference for the technique over general anaesthetic rigid cystoscopy. However, no study has yet compared the post-operative morbidity rates of these procedures. Tolerance, preference and post-operative symptoms in 100 patients undergoing local anaesthetic flexible cystoscopy were compared with those in 100 patients undergoing general anaesthetic rigid cystoscopy. On initial questioning, 89% of patients found flexible cystoscopy painless and 92% expressed a preference for the same procedure on a future occasion; 98 patients who underwent flexible cystoscopy and 87 who underwent rigid cystoscopy returned a questionnaire on symptoms 1 week after the procedure. The incidence of post-operative symptoms was 33% following flexible cystoscopy and 76% following rigid cystoscopy. Patients in both groups who were undergoing check cystoscopy had a lower incidence of morbidity than those undergoing cystoscopy for other reasons. The results suggest that flexible cystoscopy was well tolerated and preferred by most patients. The morbidity associated with the procedure was also significantly less than that associated with rigid cystoscopy under general anaesthesia.

Transrectal ultrasound of the ejaculatory apparatus.

Most interest in transrectal ultrasound (US) of the prostate has concentrated on its role in the diagnosis and management of prostatic cancer. The increasingly detailed investigation of male patients with infertility has recently led to interest in the use of US in investigating the structure and function of the ejaculatory ducts and seminal vesicles. The anatomy and pathology of the ejaculatory ducts and seminal vesicles as demonstrated by transrectal US are discussed and illustrated.