Evaluation of Presenting Symptoms and Long-Term Outcomes of Patients Requiring Excision of a Transobturator Tape (TOT).

The transobturator tape (TOT) is an effective treatment for stress urinary incontinence (SUI). Erosion of TOT mesh is a recognised complication requiring excision. A retrospective analysis of 228 females undergoing a TOT procedure over 4 years identified 16 patients (7%) that underwent excision of eroded mesh. Mean age of patients requiring excision was 48.8 years and mean weight was 72.7kg. Mean time to re-presentation was 14.5 months. Presenting symptoms included dyspareunia in 9 patients (56.2%), dysuria in 3 (18.7%), persistent incontinence in 3 (18.7%) and groin pain in one patient. Ten patients (62.5%) had a prior urogynecological procedure. After excision of eroded tape-mesh, 7 (43.7%) required a rectus fascial sling and 4 (25%) underwent repeat TOT for recurrence of SUI. Five patients (31.2%) required no further surgery. At present 10 patients (62.5%) report resolution of SUI, 4 (25%) report mild SUI and 2 (12.5%) patients have moderate/severe SUI. Resolution of symptoms occurred in the majority of patients after excision of eroded mesh and an additional anti-incontinence procedure.

Avoidable iatrogenic complications of male urethral catheterisation and inadequate intern training: a 4-year follow-up post implementation of an intern training programme.

OBJECTIVE: To assess the impact of a structured training programme in urethral catheterisation (UC) targeted at newly qualified junior doctors on rates of iatrogenic catheter morbidity within a tertiary care referral centre. SUBJECTS AND METHODS: Male UC-related morbidities were retrospectively identified from our computerised inpatient urology consultation system over a 1-year period from July 2010 to June 2011. Relevant medical records were also reviewed. Results were compared with an initial study performed between July 2006 and June 2007, prior the introduction of a structured training programme in our institution. An anonymous questionnaire was used for the subjective assessment of interns about confidence in catheterising post introduction of the programme. RESULTS: Of 725 urological consultations, 29 (4%) were related to complications arising from male UC during the 1 year period. This reflected a statistically significant decrease when compared to our 2007 figures, 51/864 (6%) (p < 0.05). Again, the most common indication for UC was monitoring urinary output for acute medical illness (19/29, 66%). The most common complication was urethral trauma (16/29, 55%). Of the 29 cases of UC-related morbidity, 18 (62%) resulted from interns performing UC, a decrease of 12% from our original paper. A drop of 27% was seen in the rates of UC related morbidity attributable to interns during the first 6 months of internship (July-December). Overall, 70% (vs 40% original study) of interns felt that their practical training was adequate since introduction of the programme (p < 0.01) with 53% considering theoretical training adequate (vs 16% original study (p < 0.01). When asked were they confident in performing UC, 63% said they were compared to 35% before introduction of the programme (p < 0.05). CONCLUSIONS: UC-related iatrogenic morbidity is not uncommon even in a tertiary-care teaching hospital. Implementation of a structured training programme in UC prior to the commencement of intern year has been shown to result in a significant decrease in the amount of iatrogenic UC related morbidity.

A review of inpatient urology consultations in an Irish tertiary referral centre.

INTRODUCTION: Our institution is a 680-bed tertiary referral centre with broad medical and surgical subspecialty services. We retrospectively audited the pattern of inpatient consultations from all specialities within our institution to the urology department over a 1-year period. METHODS: All consultations to the urology service were identified from our computerised inpatient consultation system from July 2010 to June 2011. Follow up data on investigations, interventions and subsequent outpatient appointments were also identified by review of individual patient discharge letters. RESULTS: Seven hundred and twenty five inpatient consultations were received over the period. The male to female ratio was 7:3. Mean age of patients was 66 (15-96) years. Seventy three percent of referrals were from medical sub-specialities, most commonly nephrology (17%), gastroenterology (11%) and respiratory medicine (9%). The remainder were from general surgery (16%) and other surgical sub specialities (11%). Interns (66%) and senior house officers (SHO) (28%) communicated the majority of consults. Male lower urinary tract/benign prostate related issues resulted in 25% of all consultations. Less than half of consults (47%) resulted in interventions initiated by urology, most commonly of which were catheter insertions (48%) and endoscopic procedures (35%). Only 43% of consultations were followed up in the outpatients setting. CONCLUSIONS: Inpatient consultations constitute a significant workload for urology services. The majority of these referrals did not require any urological intervention and could have been seen routinely in the outpatient setting. Providing structured referral guidelines and achieving better communication with referring teams may help to optimise this service.

Emphysematous cystitis in an elderly patient with ulcerative colitis.

Emphysematous cystitis is a rare complication of lower urinary tract infections. The disease is characterized by air within the bladder wall and lumen and commonly occurs in middle-aged diabetic women. Intramural bladder gas seen on imaging is pathognomonic for this condition. The severity of the illness varies widely from cases diagnosed incidentally to patients presenting with life-threatening sepsis. We report the case of an 80-year-old non-diabetic man presenting with emphysematous cystitis after a total colectomy for ulcerative colitis.

Primary lymphoma of the bladder: a report of three cases.

BACKGROUND: Primary lymphoma of the bladder is rare and its management is an evolving field. AIMS: To highlight primary lymphoma of the bladder as a possible diagnosis in cases of bladder neoplasm and to illustrate the currently favoured management options. METHODS: Three cases of primary bladder lymphoma are reported and management is reviewed. RESULTS: Each of the three cases was managed differently with each management approach yielding a favourable outcome. CONCLUSION: Chemotherapy combined, if necessary, with surgery or radiation therapy, should be the standard of care, depending on the full histological diagnosis.

The source of urinary nitrosamines in patients with enterocystoplasties.

OBJECTIVE: To assess the factors influencing urinary nitrosamine production in patients with enterocystoplasties. PATIENTS, SUBJECTS AND METHODS: The study comprised 100 patients with an enterocystoplasty, 20 patients with interstitial cystitis, 30 with infective cystitis and 120 control subjects drawn from hospital staff and out-patients. Urinary nitrosamine levels were measured and the urine samples cultured for microorganisms. RESULTS: Nitrosamine levels were significantly higher only in patients with enterocystoplasties who also had higher urinary white cell counts or significant bacteriuria. CONCLUSION: Patients with an enterocystoplasty and significant bacteriuria are most at risk from potential nitrosamine-induced epithelial injury.

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.

Is there a role for in vivo methylene blue staining in the prediction of bladder tumour recurrence?

OBJECTIVE: To assess the role of in vivo staining with intravesical methylene blue in predicting tumour recurrence. PATIENTS AND METHODS: Thirty-nine patients (27 men and 12 women, age range 43-75 years) newly diagnosed with bladder tumours were prospectively studied and followed for a minimum of 2 years. Potential biopsy sites were identified by staining intravesically with a 1% methylene blue solution and compared with random biopsy sites. RESULTS: Biopsy directed by methylene blue staining detected carcinoma in situ more often than random biopsy. Rates of recurrence were similar in both stained and unstained groups. CONCLUSION: Methylene blue staining does not add significantly to the management of patients presenting with bladder tumours.

Proliferating cell nuclear antigen: a new prognostic indicator in renal cell carcinoma.

Renal cell carcinoma is a tumor, the prognosis and behavior of which remain poorly understood. Proliferating cell nuclear antigen levels have been shown to act as an independent prognostic variable in a variety of malignancies. Proliferating cell nuclear antigen was evaluated in 59 cases of renal cell carcinoma, and the results were correlated with existing clinicopathological variables and survival. Proliferating cell nuclear antigen index (percentage of tumor cells positive for proliferating cell nuclear antigen) did not correlate with stage, grade or ploidy. To assess survival, tumors with proliferating cell nuclear antigen indexes of greater than and less than 60% were compared. The 24 patients with a high index (greater than 60%) had a significantly worse survival than did 35 with a low index (less than 60%, p < 0.001). Therefore, the prognostic potential of proliferating cell nuclear antigen in renal cell carcinoma is promising and may be of clinical value in the management of patients with renal cell carcinoma.

Oxygen free radicals and acute pancreatitis: fact or fiction?

The effect of oxygen free radical suppression was studied in the taurocholate model of acute pancreatitis in the rat using systemic allopurinol, superoxide dismutase (S.O.D.) and catalase. None of the treatments were beneficial which suggests that oxygen free radical suppression is unlikely to be clinically beneficial in acute pancreatitis.

In situ ESWL for ureteric calculi: the optimum treatment?

In situ ESWL for ureteric calculi is associated with good stone clearance rates but is it without significant morbidity? A review of 189 patients with single ureteric calculi (150 upper ureter, 39 lower ureter calculi) revealed an 89% stone clearance for upper ureteral calculi and 80% stone clearance for lower ureteral calculi. However 11% of patients with upper ureteral calculi and 20% of patients with lower ureteral calculi required additional intervention for complications or failed treatment. In situ ESWL may not be the optimum therapy for all ureteric calculi especially those in the lower ureter.

Do not treat staghorn calculi by extracorporeal shockwave lithotripsy alone!

A review of 84 patients with triple phosphate (staghorn) calculi treated by extracorporeal shockwave lithotripsy (ESWL) revealed a 67% stone clearance at 6 months. Classification of calculi according to morphology showed a variation in stone clearance from 47 to 82%. A significant number of patients developed complications (25%) or required additional procedures (27%). ESWL monotherapy is not a suitable treatment option for most patients with staghorn calculi.

Older donors and kidney transplantation.

Reluctance to use kidneys from older donors (> 50 years of age) is based on reports of inferior results. We reviewed our experience with 45 kidneys transplanted from older donors. Primary nonfunction, immediate graft function, and 1-, 2- and 3-year graft survival rates were similar to those obtained with kidneys transplanted from donors aged between 20 and 40 years. Renal function at 1 year (as measured by serum creatinine) was poorer in kidneys from older donors. No beneficial effect with respect to graft survival was noted with cyclosporin therapy compared to conventional immunosuppression; however, the numbers are small. We conclude that kidneys from older donors are a valuable source for transplantation.

A novel method of induced renal hypothermia.

When the kidney is removed from cold storage for implantation into the recipient it gradually rewarms (second warm ischaemic time) and a prolonged second warm ischaemic time is a risk factor for delayed graft function. A cooling jacket has been designed to prevent this rewarming during transplantation. This study evaluates the efficacy of this device. Surface and core temperatures of less than 15 degrees Centigrade were maintained for 120 minutes. Renal function was significantly better in cooled than in uncooled kidneys in a single kidney canine model. Induced renal hypothermia, using a device such as this, should be a routine manoeuvre in renal transplantation.

Local beneficial effect of coumarin in experimental peritonitis.

Coumarin, a potent immune stimulant and macrophage activator, has been used to treat brucellosis and as an immune suppressor. The effect of Coumarin and systemic antibiotics on septicaemia, survival and peritoneal contamination in experimental peritonitis was assessed. Four groups of male Sprague-Dawley rats were inoculated with Clostridium perfringens, Escherichia coli and Bacteroides fragilis. Group A received saline alone, Group B received Coumarin alone, Group C received antibiotics (Clindamycin and Cephradine) alone and Group D received both Coumarin and antibiotics. Septicaemia, confirmed by blood culture, occurred in all animals. Coumarin did not improve survival whether given alone or in combination with antibiotics. Animals given Coumarin (Groups B and D) had significantly less peritoneal soiling (54%, 0%) (P less than 0.02, P less than 0.001) than their controls (Groups A and C: 92%; 29%). While Coumarin did not improve resistance to septicaemia it did exert a local beneficial effect.

A canine model of cyclosporine enhanced ischemic renal injury.

Clinical reports of increased graft primary non function in patients receiving cyclosporine in whom the anastomosis time is prolonged (greater than 30 minutes) suggest a synergism between the nephrotoxic effects of cyclosporine and the ischaemia occurring during transplantation. Using unilaterally nephrectomised greyhound dogs, sixty minutes ischaemia and cyclosporine 10 mg./kg./day we have produced an animal model of cyclosporine enhanced ischaemia renal failure. Structural and functional data suggests the proximal tubule is the main site of injury.