Helmets and haematomas.

This report discusses two cases referred on the same day to the Mersey Regional Neurosurgical Unit. Both patients bore positions of responsibility and each developed an extradural haematoma as a result of neglecting to wear the appropriate safety helmet for their respective sports. The two survived, without detectable morbidity, to learn the relevant lesson.

Actinomycotic vesico-uterine fistula from a wishbone pessary contraceptive device.

PIP: Presented is the case of a 77-year-old British women with sudden onset of vaginal bleeding and a 3-year history of urinary incontinence. A wishbone-type pessary, inserted in 1945 and never removed, was found to be the source of these symptoms. Cystoscopy revealed a large fistula at the bladder base, and bacterial culture of the pyometra grew bacteroides and actinomyces. The symptoms abated after closure of the fistula and antibiotic treatment. This is the first report of a vesico-uterine fistula due to a wishbone pessary. In the other similar case reported in the literature, a vesico-uterine fistula was related to a Maslin Spring IUD that had been inserted 14 years prior to presentation. The IUD is an ideal predisposing factor for the development of pelvic actinomycosis.^ieng

Late erosion. A new complication of artificial urinary sphincters.

A hitherto unreported long-term complication of artificial sphincter implantation--delayed erosion--is described.

Assessment of the long-term results of subtrigonal phenolisation.

Long-term follow-up was conducted on 97 patients who had undergone subtrigonal phenolisation for detrusor instability, bladder hypersensitivity, detrusor hyper-reflexia or interstitial cystitis. The procedure failed to alleviate lower urinary tract dysfunction in 57% of patients; it had an unsustained benefit in 24% and long-term success was experienced by only 19%. It was most effective in the hypersensitive bladder of unknown cause. The incidence of complications (17%) suggests that the procedure should only be undertaken if more invasive measures are the only available alternative, and the possibility of these complications should be explained to the patient.

Assessment of the poorly contractile or acontractile bladder in the older male in the absence of neuropathy.

Up to 30% of patients who undergo prostatectomy are left with residual symptoms. Most have persistent detrusor instability, but some have poorly contractile or acontractile bladders. Over a 2-year period, 42 neurologically normal patients were shown to have a hypocontractile or acontractile bladder on urodynamic testing; 27 had undergone outflow tract surgery. Four patients who were totally incontinent had undergone at least 2 transurethral resections. The remainder had severe frequency, urgency and nocturia. Urodynamically, all but 7 patients with poor compliance had normal filling cystometrograms, all but 8 had residual urine volumes less than 100 ml, and 26 had less than 5 ml. Thus their symptoms are difficult to explain. Apart from the insertion of an artificial sphincter in those with total incontinence, treatment did not improve any of these patients.

The role of urodynamic studies in the evaluation of patients with augmentation cystoplasties.

OBJECTIVE: To assess the role and value of videourodynamic studies (VUD) in the post-operative evaluation of 100 patients who were continent following augmentation (clam) enterocystoplasty. PATIENTS AND METHODS: Fifty patients had non-neuropathic detrusor instability and 50 had neuropathic bladder dysfunction. All underwent standard dual channel medium fill cystometry and synchronous video screening before and at 6 months and 2 years after a clam ileocystoplasty. RESULTS: Pre-operative capacity was variable in non-neuropathic patients but post-operative capacity in this group, and both pre- and post-operative capacity in the neuropathic group, were more reproducible. Of non-neuropathic patients, 88% became stable and 83% became normally compliant, compared with only 38 and 50% respectively of neuropathic patients. More surprisingly, two of eight neuropathic patients previously stable became unstable and four of 12 of those previously normally compliant became poorly compliant. In all patients voiding spontaneously there was a tendency for capacity to increase and voiding efficiency to decrease with time. CONCLUSIONS: From these results, standard VUD studies contributed little to the post-operative assessment of patients with clam cystoplasties beyond that which could be obtained by ultrasonography of the bladder before and after voiding. The effect or lack of effect of augmentation cystoplasty on compliance in the neuropathic bladder suggests a neuropathic effect on bowel contractility and warrants further investigation. The meaning and significance of 'urodynamic' observations when bowel is incorporated into the bladder also needs careful investigation.

Pregnancy after lower urinary tract reconstruction in women.

PURPOSE: We determined if pregnant women with reconstructed lower urinary tracts experience complications related to the urological reconstruction. MATERIALS AND METHODS: A total of 27 women (34 pregnancies) with reconstructed lower urinary tracts underwent regular urinalysis, blood biochemistry studies and ultrasound examinations during pregnancy and for a minimum of 1 year after delivery. RESULTS: There were 28 normal, full-term vaginal deliveries without complication. A total of 6 patients underwent cesarean section, with injury to the vascular pedicle of the cystoplasty without sequelae occurring in 1. Temporary postpartum incontinence occurred in 6 patients. CONCLUSIONS: Patients with reconstructed lower urinary tracts can experience normal deliveries but require close surveillance. The route of delivery should be determined by obstetrical indications.

Night studies for primary diurnal and nocturnal enuresis and preliminary results of the "clam" ileocystoplasty.

Modified conventional urodynamic apparatus was used to provide overnight monitoring of bladder and rectal pressure. A group of 26 patients with primary diurnal and nocturnal enuresis underwent both daytime rapid fill cystometry and overnight natural fill cystometry. The overnight study was effective in detecting detrusor instability in 10 patients deemed normal on rapid fill cystometry; 6 of these have now undergone clam ileocystoplasty and 5 are dry; 3 are awaiting this procedure. The clam remains very effective in the management of patients with resistant nocturnal and diurnal enuresis if careful selection is adopted. Overnight cystometry has proved to be an invaluable adjunct to the investigation of patients with primary diurnal and nocturnal enuresis previously felt to be urodynamically normal.

Ambulatory urodynamics.

Long-term ambulatory urodynamic monitoring has been employed in 20 patients in an attempt to detect detrusor abnormality not appreciated by conventional cystometry. In 9 female patients with the "urge syndrome" it detected 2 previously unrecognised cases of detrusor instability; in 4 enuretic patients, only 1 of whom was known to be unstable previously, unstable contractions were confirmed, and 2 of 7 cystoplasty patients had high amplitude contractions detected only on ambulatory assessment. The technique provides a more sensitive index of lower urinary tract function than conventional cystometry in such patients.

Permanent urethral stents for detrusor sphincter dyssynergia.

A series of 22 patients, most of whom had spinal injuries with detrusor sphincter dyssynergia, have had Medinvent Wallstents placed across the distal mechanism. All but 8 patients had undergone outflow surgery and 11 had had repeated unsuccessful sphincterotomies. The proximal end of the stent was placed over the verumontanum unless fertility was contemplated, when it was placed immediately below the verumontanum. Fifteen patients achieved complete voiding after placement of the first stent; 3 developed bladder neck obstruction after stenting, but in 1 of these cases resolution occurred after bladder neck incision. The 3 patients with artificial urinary sphincters failed to improve after stenting. Use of the urethral stent for patients with detrusor sphincter dyssynergia and failed sphincterotomy is a major advance. It should probably be the primary treatment in selected cases. Its effect on fertility is currently under assessment.

The effect of intravesical Marcain instillation on hyperreflexic detrusor contractions.

Thirty-six patients with suprasacral spinal injury were treated with intravesical local anaesthetic instillation. Eighteen of 32 patients (56%) were converted from an 'ice water positive' hyperreflexic state to an 'ice water negative' state by bupivacaine hydrochloride. Four patients treated with lignocaine hydrochloride showed no benefit. Intravesical local anaesthetic instillation is suggested as a possible treatment for selected cases of detrusor hyperreflexia in patients on intermittent catheterisation.

Is cystoplasty a safe alternative to urinary diversion in patients requiring renal transplantation?

The study aimed to assess the methods of urinary drainage in patients requiring renal transplantation in whom the native lower urinary tract was unsuitable. Twenty-one patients had a transplant into an abnormal urinary tract. Eight of them into a cystoplasty, 8 into an ileal conduit and 5 had a cutaneous ureterostomy. All patients transplanted into an ileal conduit (mean follow-up 4.6 years) and into a cutaneous ureterostomy (mean follow-up 3.2 years) have had a satisfactory outcome. Five of 8 patients transplanted into a cystoplasty have had a satisfactory outcome, 2 patients suffered graft loss due to rejection and 1 developed necrosis of cystoplasty following transplantation. In terms of graft survival, excellent results in the medium term were obtained for transplantation with an ileal conduit or cutaneous ureterostomy. Cystoplasty was less successful but was not the direct cause of graft loss in any patient and as such is as safe a technique in patients with end-stage renal failure so long as care is taken to avoid the vascular pedicle at the time of transplantation.

Stones in enterocystoplasties.

OBJECTIVES: To assess the aetiology of stones which occur in enterocystoplasties and continent diversions, generally attributed to the presence of foreign material, e.g. staples, or to recurrent urinary infection, in patients with augmented or substituted bladders. PATIENTS AND METHODS: The study comprised 467 patients who had undergone reconstruction of the lower urinary tract and had been followed up for at least 3 years using videourodynamics and ultrasonography. RESULTS: Stones were found in 42 patients (9%); 50% were found incidentally and the remaining patients presented with symptomatic infections (27%) or deterioration in urinary continence (23%). Stones occurred in 6% of patients with augmentation, in 7% of those with substitution cystoplasty and in 22% of patients with continent diversions. Most patients with stones (88%) used clean intermittent self-catheterization (CISC). Stones were 5-10 times commoner in patients using CISC than in patients voiding spontaneously. CONCLUSION: Urinary stasis was a more important cause of stone formation than was bacteriuria in patients with cystoplasty. The presence of mucus and bacteriuria are presumed to be contributory. To reduce the risk of stone formation, orthotopic cystoplasty and spontaneous voiding are to be preferred to continent diversion and CISC. Periodic bladder washouts may be an alternative solution.

Spontaneous haemoperitoneum from rupture of a primary hepatic adenoma in an adult man.

Hepatic cell adenomata have been described as the rarest of benign liver tumours. Their incidence has increased with the advent of the oral contraceptive pill and they have been reported to rupture spontaneously in women. In men such a phenomenon appears to be an extreme rarity and, to our knowledge, spontaneous rupture of an uncomplicated primary hepatic adenoma, in an adult man, is previously unrecorded.