The effects of spinal anesthesia with lidocaine and sufentanil on lower urinary tract functions.

BACKGROUND: Spinal local anesthetics interrupt the micturition reflex; bladder function remains impaired until sensory block had regressed to the S3 segment. Intrathecal opioids cause dose-dependent suppression of detrusor contractility. We studied the effects of spinal anesthesia with a combination of lidocaine and sufentanil on lower urinary tract function. METHODS: Filling cystometry was performed in 10 healthy young male patients undergoing elective lower limb orthopedic surgery. After baseline recordings, each patient received spinal anesthesia with 100 mg hyperbaric lidocaine combined with 20 microg sufentanil. In the postoperative phase, regressions of sensory and motor block were recorded and urodynamic measurements continued until the patient could void spontaneously without residual volume in the bladder. RESULTS: The mean (SD) time to recovery of urge was 240 (37) min after spinal injection, but no patient was able to void at that time. Six patients experienced urge at the previously observed maximum bladder capacity when the sensory block had regressed to the second sacral segment (S2), in four patients to S3. Despite this urge, no detrusor contraction was recorded. The patients were able to completely empty the bladder 332 (52) min after spinal injection. The average time difference between recovery of urge and return of normal bladder emptying was 90 min. CONCLUSION: Bladder contractility returns much later than recovery of sensory function in sacral dermatomes (S3) when hyperbaric lidocaine combined with sufentanil is used for spinal anesthesia.

High-dose exposure to valsartan with suicidal intention.

Valsartan is a strong angiotensin receptor inhibitor specific for the angiotensin I receptor, which has been proven safe and well-tolerated in clinical trials. We were able to confirm its safety and tolerability in a case of high-dose exposure to valsartan with suicidal intention. A 25-year-old, fully conscious, female patient was brought to our hospital by relatives on July 24, 2001, at 9:15 p.m. following intake of a high dose of valsartan. It was established that she had taken 28 Diovan 80 mg tablets (2.24 g) 5 hours before admission to the hospital. Her clinical condition at the time of admission was good and did not deteriorate after admission. During the follow-up, her blood pressure never fell below 90/60 mmHg. The only complaint she had were painful muscle cramps which, with only supportive therapy, disappeared spontaneously over 2 days, and her blood pressure also returned to normal during this period. This report demonstrates the effect/side effect profile of valsartan when taken at a high dose, not achievable in a clinical trial.

[Social and functional results of brachial plexus birth injury].

Long-term results of obstetrical brachial plexus injury were studied. The medical records of 10 females and 9 males (range 16-59 years, mean 27.8) who responded to a questionnaire were reviewed. According to the responses, they all had been leading normal lives, despite various degrees of impairment.

Diagnostic and predictive value of voiding diary data versus prostate volume, maximal free urinary flow rate, and Abrams-Griffiths number in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

OBJECTIVES: To investigate the information of voiding data in relation to symptoms and well-being in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and to compare this information with that of prostate volume (Vprostate), maximal free urinary flow rate (Q(max,free)), and obstruction grade (OG). METHODS: We performed mandatory tests, recommended tests, and pressure-flow studies in 384 consecutive men with LUTS suggestive of BPH. We estimated nocturia, diuria, and mean voided volume (Vmean) from their voiding diaries. Symptoms and well-being were quantified by American Urological Association symptom index (SI), quality-of-life score (QoL), symptom problem index (SPI), and BPH impact index (BII). We investigated the influence of Vprostate, Q(max,free), OG, Vmean, nocturia, and diuria on SI, QoL, SPI, and BII. We re-evaluated 48 men 6 months after transurethral resection of the prostate (TURP). We analyzed the predictive value of preoperative Q(max,free), Vprostate, OG, Vmean, nocturia, and diuria for the improvements of SI, QoL, SPI, and BII after TURP. We studied the improvements of Q(max,free), OG, Vmean, nocturia, and diuria after TURP and the improvements of SI, QoL, SPI, and BII. RESULTS: Prostate volume, Q(max,free), and OG were only slightly associated with SI, QoL, SPI, and BII, in contrast to Vmean, nocturia, and diuria. The predictive value of all parameters on the outcome of TURP was poor. Improvements of all parameters were strongly associated with improvements of SI, QoL, SPI, and BII after TURP. CONCLUSIONS: Voiding data should have a prominent role in the initial evaluation of men with LUTS suggestive of BPH.

Invasively estimated International Continence Society obstruction classification versus noninvasively assessed bladder outlet obstruction probability in treatment recommendation for LUTS suggestive of BPH.

OBJECTIVES: To investigate the contribution of urodynamically proven presence or absence (International Continence Society classification) of bladder outlet obstruction (BOO) to treatment recommendations for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia, and to investigate the impact of the replacement of the invasively estimated BOO classification with the noninvasively assessed BOO probability on treatment recommendations. METHODS: Mandatory tests, recommended tests, and pressure-flow studies (with BOO classification) were performed in 150 consecutive men with LUTS suggestive of BPH. Three experienced urologists proposed, independently of each other, the treatment for each patient: watchful waiting, pharmacologic treatment, or surgery. After repeat randomization of the patients and replacement of the BOO classification with the BOO probability, the procedure was repeated 1 month later. A third treatment proposal was done after repeat randomization and after replacement of the BOO probability with the BOO classification. RESULTS: The symptom score and quality-of-life score were the most decisive in the treatment recommendations, followed by the BOO probability and BOO classification. The medical history, physical status, and duration of the complaints did not significantly affect the treatment recommendations. The intraindividual agreement between the judgments that included the BOO classification and the judgments that included the BOO probability was comparable to the agreement between both judgments that included BOO classification. The interindividual agreement between the judgments that included the BOO classification was not significantly different from that of the judgments that included the BOO probability. CONCLUSIONS: The symptom score and quality-of-life score were the most decisive in the medical treatment recommendations, followed by the BOO probability and BOO classification. The noninvasively assessed BOO probability was as valuable as the invasively estimated BOO classification in the medical treatment recommendations.

Long-term follow-up after laser therapy for penile carcinoma.

OBJECTIVES: Although in many cases of penile carcinoma, laser therapy has become the standard treatment, opinion still differs regarding the risks related to the relatively high rate of recurrence that accompanies this form of treatment. In this study, we reviewed the results of neodymium:yttrium-aluminum-garnet laser treatment of 44 consecutive patients with penile carcinoma in our institution from 1986 to 2003. METHODS: We created five groups, on the basis of the T stage and grade of the tumor. Of the 44 patients, 21 had Stage T1, 17 had Stage T2, and 6 had carcinoma in situ. RESULTS: Local disease recurrence (in the treated area) occurred in 48% of the treated patients, and in 20% of the patients, the first recurrence was elsewhere on the glans penis. These were subsequently treated by laser therapy or partial amputation. In 10 cases, nodal metastases were found. Eight of these cases were Stage T2. Our results suggest a stronger prognostic role for the primary T stage of the tumor than for the tumor grade, with respect to the risk of nodal metastasis. CONCLUSIONS: From the high recurrence rate in our series, we decided to perform a wider initial laser excision and to diminish the number of retreatments to less than three. We also now believe that laser therapy is best for Stage Tis and T1 tumors exclusively. Only selected patients with T2 tumors should be treated in combination with early lymph node resection.

Congenital constriction band syndrome.

A retrospective study of 55 patients with congenital constriction band syndrome was performed. Multiple extremity involvement was found to be the most common clinical feature associated with the disease, and 34% of the patients studied were premature at birth. Malformations included constriction bands, clubfoot, intrauterine amputation, syndactyly, and acrosyndactyly (fenestrated syndactyly). The extremities were most often affected distally, involving the longer central fingers and medial two toes. More proximal involvement with constriction bands was associated with a higher frequency of neurologic deficit. Significant leg-length discrepancy exceeding 2.5 cm was seen in 9 of 38 patients (24%) with lower extremity involvement, a condition that has not been previously reported.

Double fingernails on the small fingers.

This report describes the unusual presence of dorsal skin and a fingernail on the palmar surface of both small fingers, with a normal nail on the dorsal surface. This child has a normal karyotype. There has been one previous report in the literature of a similar anomaly associated with a chromosome 6 abnormality.

Evaluation of a uniform operative technique to treat syndactyly.

Twenty-two patients with upper extremity syndactyly (58 webs) have been treated in the last decade (1976 to 1985) by one hand surgeon using one technique. Nineteen patients had syndrome complexes or other associated anomalies that made treatment more difficult. The postoperative follow-up averaged 4 years. The rate of complications that necessitated repeat operations (5% of the treated webs) was relatively low in comparison with those in other series. We attribute this to better timing of the procedure and progressive experience gained by one surgeon using the same procedure.

Macrodactyly involving both hands and both feet.

A case is reported of a child with macrodactyly of both hands and both feet and very rare postaxial involvement of the upper limbs.

The management of trigger thumb in children.

Trigger thumb in children is an uncommon condition. We reviewed 41 patients with 53 trigger thumbs. Although the current accepted approach to the treatment of congenital trigger thumbs is a prolonged period of observation, our findings indicate that all of our patients eventually required surgical release of the flexor pollicis longus tendon. Waiting 3 years before a surgical release was done did not affect the surgical result.

Evaluation of the operative treatment of syndactyly.

A review of the records of 61 patients with 176 surgically treated webs was completed to evaluate the results of the different operative techniques used to separate the fingers. The postoperative follow-up period averaged 14 years, with a range from 2 to 38 years. The patients were assessed in two groups: those with major associated anomalies and those in whom syndactyly was the principal anomaly. Recurrence of the webs and flexion and extension contractures occurred more often when split-thickness grafts were used. To obtain a satisfactory result, a second procedure was necessary in 59% of patients with major associated anomalies, and in 30% of the patients who had syndactyly as the principal abnormality. Two types of patients were found to require subsequent operations: children treated prior to 18 months of age and those with complex syndactyly.

Abnormal dermatoglyphics in arthrogryposis multiplex congenita.

Dermatoglyphic abnormalities have been found in patients with arthrogryposis multiple congenita. These unusual features, which appear to be pathognomonic, indicate an early prenatal pathogenesis and may aid in differential diagnosis.

Congenital radial head dislocation.

Fifty patients with 77 congenitally dislocated radial heads were reviewed to assess the diagnostic features, functional limitations, symptomatology, and results of treatment. Twenty-three patients had associated anomalies of the affected upper extremity, and 35 had anomalies in other parts of the body. In six patients no other anomaly was found, all six had bilateral involvement. No patient had congenital radial head dislocation as a unilateral isolated anomaly, and therefore we doubt its existence. Functional limitation with congenital radial head dislocation is minimal and pain is uncommon. Radial head excision relieves pain and improves appearance: however, it does not increase motion.

Bone cement and antibiotics.

Antibiotics of various kinds were added to the powdered polymer of methylmethacrylate in a concentration of 1 g antibiotic/40 g cement, prior to the addition of the liquid monomer. Specimens were subjected to mechanical testing by loading them in direct compression on a 20-ton Instron Universal Testing Machine, and load deflection curves were recorded. It was found that the addition of antibiotics does have an effect on the mechanical strength of the cement--the loss was small, less than 10% for both the compressive strength and the elastic modulus, provided the antibiotic was in powder form. Liquid antibiotics resulted in a greater loss of the compressive strength of the mixtures, but specimens tended to be less porous. In vitro studies of the antibiotic properties of the mixtures demonstrated potent antibacterial activity in all the antibiotics tested, except chloramphenicol. Possible clinical applications are discussed. Further in vivo studies are needed before widespread clinical use can be advocated.

Osteoid osteoma of the proximal femur: new techniques in diagnosis and treatment.

The nonspecific symptoms and radiographic findings associated with osteoid osteoma in the proximal femur mimic inflammatory conditions and delay diagnosis. A review of four cases showed high resolution computerized axial tomography in conjunction with a radioisotope bone scan best demarcated the location and size of the lesion. The combination of careful preoperative localization and intraoperative use of a radiation probe made adequate resection possible while limiting the amount of bone excised. This technique eliminated the need for internal fixation and reduced the duration of the recovery period.

Data from frequency-volume charts versus maximum free flow rate, residual volume, and voiding cystometric estimated urethral obstruction grade and detrusor contractility grade in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

AIMS: To examine associations of data from frequency-volume charts with maximum free flow rate, residual volume, and voiding cystometric estimated urethral obstruction grade and detrusor contractility in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH). METHODS: The 160 men included in the study met the criteria of the International Scientific Committee on BPH, i.e., they voided more than 150 mL during uroflowmetry, their residual volume and prostate size were estimated, and they completed frequency-volume charts correctly. From the frequency-volume charts, voiding habits and fluid intake were evaluated. Pressure-flow studies were performed as well. RESULTS: Increasing residual volume was related to a decrease of maximum voided volume and to a decrease of maximum free flow rate. Cystometric capacity was little affected by residual volume. Low contractility did not result in high residual volume. A marked decrease in voided volumes with increasing obstruction grade was observed, due to a decrease of cystometric capacity and an increase of residual volume. Detrusor contractility was little associated with voided volumes. A higher voiding frequency was related to a higher fluid intake. However, increased standardized frequency (number of voidings per 1,000 mL) was associated with a substantial reduction of fluid intake. CONCLUSIONS: Infravesical obstruction is the most important factor influencing voided volumes, cystometric capacity, and residual urine volume. Frequency of voiding was not influenced significantly because patients with small voided volumes minimized their fluid intake.

Noninvasive assessment of prostatic obstruction in elderly men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVES: To investigate what combination of easily available parameters allows the noninvasive prediction of infravesical obstruction in optimal agreement with urodynamic classification. Urodynamically, men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia are classified as nonobstructed or obstructed. METHODS: Mandatory and recommended tests were performed in 160 consecutive men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. The classification of the International Continence Society, the group-specific urethral resistance factor, and Schäfer's obstruction grade were estimated from urodynamic studies. The frequency-volume charts were analyzed. A separate group of 173 consecutive men was used for validation. RESULTS: The formula, prostate volume (in cubic centimeters) - 3 x maximal urinary free flow rate (in milliliters per second) - 0.2 x mean voided volume (in milliliters; as estimated from frequency-volume charts), was optimal in the classification compared with the urodynamic classification. Extension of this formula to more than three parameters did not result in better selection. As estimated from receiver operating characteristic curves, the accuracy of the formula appeared to be good. The method of quantifying urethral resistance minimally affected the classification that resulted from the combination. From the results, a diagram was created presenting the probability of an individual to have infravesical obstruction. The validation results were satisfactory. CONCLUSIONS: The prediction of the probability of a man with lower urinary tract symptoms suggestive of benign prostatic hyperplasia to have infravesical obstruction can be deduced from a diagram based on a formula composed of three readily available parameters: prostate volume, maximal urinary free flow rate, and mean voided volume.