Clinical and economic consequences of volume- or time-dependent intermittent catheterization in patients with spinal cord lesions and neuropathic bladder.

STUDY DESIGN: Open comparative study. OBJECTIVE: To compare the impact of volume-dependent intermittent catheterization (VDIC) and time-dependent intermittent catheterization (TDIC) on financial burden and clinical outcomes in patients with spinal cord lesions (SCL). SETTING: Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Israel. METHOD: Economic and clinical outcomes were examined in 13 SCL patients treated with VDIC following bladder volume measurement by a portable ultrasound device (the study group), and in 11 patients treated with TDIC (the control group). Patients were followed for 12-30 days. Costs were calculated according to December 2003 prices at Loewenstein Hospital. The t-test and the Fisher's Exact Test were employed for comparisons between the groups. RESULTS: The number of catheterizations per patient per day, the time required to perform volume measurements and catheterizations, and their total cost, were approximately 44, 49, and 46% lower in the study group than in the control group. SCIMU (representing bladder management functioning) increased during the study in both groups, and the increase was 31% higher in the study group than in the control group. Urinary infection was found in three patients in the control group and in none in the study group. CONCLUSION: VDIC has economic and probably also clinical advantages over TDIC.

Bladder tone in patients in post-traumatic vegetative state.

The aim of the present study was to examine the bladder tone in vegetative patients using urodynamic tests. The study population consisted of 17 patients, 13 men and four women, in a post-traumatic vegetative state under treatment at the Loewenstein Rehabilitation Centre. Time since injury ranged from 1 to 6 months. Cystometry results indicated that 100% of the patients had neurogenic bladder, hypertonic type, two (12%) with mild spasticity and 15 (88%) with severe spasticity. None showed detrusor-sphincter dyssynergia or unstable bladder. Based on these unequivocal findings, it is suggested that all patients in trauma-induced vegetative state be treated prophylactically from the 2nd week with anticholinergic agents.

Leiomyoma of the urinary bladder.

Leiomyoma of the urinary bladder is a rarity but should be considered in the differential diagnosis of intramural neoplasm. We report a case illustrating clinical and pathological features in particular the immunohistochemistry. Etiology and differential diagnosis are discussed.

Transvesical prostatectomy in elderly patients.

PURPOSE: We assessed the results of transvesical prostatectomy in patients older than 80 years. MATERIALS AND METHODS: We studied 98 patients 80 to 90 years old who underwent transvesical prostatectomy between 1986 and 1993, including those with a large prostate (preoperative estimated weight more than 80 gm.), numerous or large cystolithiasis and large bladder diverticulum, which are indications for open prostatectomy. Clinical data were obtained by chart review. RESULTS: The indications for surgery were urinary retention in 53 patients (54%), severe obstructive urinary symptoms in 18 (18.4%), cystolithiasis in 17 (17.3%), prostatic bleeding in 10 (10.2%) and bladder diverticulum in 2 (2%). Accompanying diseases were present in 69 patients (70.6%), including ischemic heart disease in 41 (42%), diabetes mellitus in 17 (17.3%) and arterial hypertension in 14 (14.3%). A total of 59 patients (60.2%) underwent surgery while under general anesthesia and 39 (39.8%) received regional anesthesia. Average operative time was 62 minutes. Of the patients 40 (40.8%) received 1, 14 (14.3%) received 2 and 2 (2%) received 4 units of blood. No postoperative deaths or life threatening complications were noted. The immediate postoperative complications included urinary tract infection in 20 patients (20.5%), wound infection in 3 (3.0%) and orchiepididymitis in 3 (3.0%). Postoperative mild to moderate incontinence was noted in 2 patients (2.0%). Bladder neck constriction and urethral strictures occurred in 4 (4.1%) and 3 (3.0%) patients, respectively. CONCLUSIONS: Transvesical prostatectomy can be performed safely in elderly patients with a low morbidity rate.

The role of external sphincterotomy for patients with a spinal cord lesion.

For the last three decades external sphincterotomy has been well accepted as a treatment for bladder outlet obstruction in patients with a spinal cord lesions. Recently, however, its value has been brought into question. To assess the current place of this procedure in the treatment of the neuropathic bladder of spinal origin, we studied the outcomes of sphincterotomy in 32 patients. Post-voiding residual urine volume decreased after surgery in 27 patients (84%), considerably in 22 (69%) of them. Clinical infection resolved in 14 out of 19 patients (74%), hydronephrosis disappeared in two out of three (66%), and vesicourethral reflux improved in three out of five (60%) and was cured in two (40%). Six of the patients (19%) were freed from catheterization, but two patients (6%) lost partial continence. Sphincterotomy is an important tool in the treatment of spinal patients with bladder outlet obstruction and should be considered when the proper indications exist.

The pattern of radionuclide scrotal scan in torsion of testicular appendages.

The aim of this study was to define the radionuclide scrotal imaging (RSI) pattern in cases of torsion of testicular appendages and to correlate it with the duration of symptoms. Two hundred and seventeen patients with acute scrotal pain were evaluated prospectively during the past 13 years. Two groups of patients were defined according to the interval between the onset of symptoms and the performance of RSI: group A comprised patients in whom RSI was performed within 5 h after the onset of symptoms, while group B comprised patients in whom RSI was performed between 5 and 24 h after the onset of symptoms. An SPX-4 Elscint or an Apex 405 gamma camera with a parallel hole or converging collimator was used. Between 5 and 15 mCi of technetium-99m pertechnetate was injected as a bolus intravenously. The radionuclide angiogram consisted of six to eight consecutive 5-s frames. The scrotal static scan was obtained immediately following the radionuclide angiogram. The "hot dot" sign, which is a small spot of increased tracer perfusion and uptake on RSI, was not present during the first hours after the onset of symptoms. Therefore, RSI is inaccurate and is not indicated for the diagnosis of torsion of testicular appendages of less than 4-5 h duration. The hot dot sign was, however, demonstrated on the RSI in 45% of the patients with scrotal pain lasting between 5 and 24 h. The overall sensitivity and accuracy of RSI in diagnosing torsion of testicular appendages in this group of patients were 68% and 79%, respectively. In all the patients with a positive hot dot sign, torsion of testicular appendages was found at exploration (specificity 100%). Therefore, the hot dot sign was found to be pathognomonic of torsion of testicular appendages.

Changing trends in the management of iatrogenic ureteral injuries.

PURPOSE: We evaluated changing trends in the management of late diagnosed iatrogenic ureteral injuries before and after the introduction of percutaneous nephrostomy. MATERIALS AND METHODS: The study included 44 patients of whom 24 were treated primarily by immediate reconstructive surgery from 1979 to 1984 and 20 were treated primarily by percutaneous nephrostomy tube insertion beginning in 1985. RESULTS: Six of the 24 patients underwent ureteroneocystostomy and 18 underwent end-to-end uretero-ureteral anastomosis to repair the injury. Postoperatively 18 patients had a urinary tract infection. Hospital stay after reconstructive surgery ranged from 14 to 35 days (average 18). Long-term followup showed a normal upper urinary tract in 22 patients and mild to moderate hydroureteronephrosis in 2. Of the 20 patients who underwent percutaneous nephrostomy 16 (80%) had complete spontaneous recovery of the injured ureter after 14 to 66 days (average 32). Hospital stay after the insertion of the percutaneous nephrostomy tube ranged from 3 to 5 days. Urinary tract infection developed in 4 patients and mild hydronephrosis was noted in 1 on long-term followup. CONCLUSIONS: The primary management of ureteral injury by percutaneous nephrostomy resulted in significantly decreased reoperation and morbidity rates, and enabled spontaneous recovery of the injured ureter in the majority of patients.

Acute appendicitis in a premature baby.

Acute appendicitis with perforation in a premature baby, weighing 1 050 g, is described. Initially the infant did well after surgery, but succumbed to sepsis, as a result of hyperalimentation, eleven days later. This is the smallest infant suffering from appendicitis reported in the English literature.