Nephrobronchial fistula - a case report.

We report the case of a 58-year-old woman with a hydronephrotic left kidney who presented with a 4-month history of anorexia, weight loss and intermittent left loin pain associated with cloudy urine. Her urine grew lactose fermenting coliforms, and was treated with antibiotics. A computerized axial tomography scan (CT scan) was equivocal and she underwent retrograde ureteric stenting, which drained a pyonephrosis. She went on to develop a chest infection due to a lung abscess. A CT scan revealed a left perinephric collection extending across the diaphragm into the lower lobe of the left lung. She responded to antibiotics and awaits a nephrectomy.

Heat shock protein expression independently predicts clinical outcome in prostate cancer.

Heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis, and differential expression of individual hsps occurs in a broad range of neoplastic processes. This study was performed to test the hypothesis that the particular patterns by which individual hsps become specifically modulated in human prostate cancers are correlated with behavioral phenotype and hence may be of value in determining the most appropriate clinical management of individual patients. Monoclonal antibodies specific for each hsp protein were used to assess expression of hsp27, hsp60, and hsp70 in formalin-fixed, paraffin wax-embedded, archival tissue specimens of early prostatic adenocarcinomas (pT1-2N0M0) removed at radical prostatectomy (n = 25) and in advanced cancers (n = 95) identified at transurethral resection of prostate (TURP). These findings were compared with similar data from control prostates (n = 10) removed at primary cystectomy for urinary bladder neoplasia not involving the prostate and also at TURP for benign prostatic hyperplasia (n = 50). Western blotting of whole cell lysates derived from established human prostatic epithelial cell lines PNT2, LNCaP, DU145, and PC3 was compared with expression of hsps by the primary human tissues. This study found that early in situ neoplastic transformation of normal prostatic epithelium was consistently associated with loss of hsp27 expression and that the level of hsp27 expression by individual prostate cancers was correlated with their Gleason grade. In advanced cancers, hsp27 expression was invariably associated with poor clinical outcome (P = 0.0001). Data from cell lines supported the primary tissue findings, with elevated hsp27 expression only in aggressive malignant cell lines and androgen-insensitive cell lines. Expression of hsp60 was significantly increased in both early and advanced prostate cancer when compared with nonneoplastic prostatic epithelium (P < 0.0001), as well as in malignant prostate cancer cell lines. Expression of hsp70 was unaltered in early prostate cancers when compared with nonneoplastic prostatic epithelium but showed a diminished expression in morphologically advanced cancers (P = 0.0029). No consistent correlation was found between levels of hsp60 or hsp70 expression and phenotypic behavior of individual primary prostatic cancers. Thus, patterns of hsp expression have been confirmed to be specifically and consistently modulated in both early and advanced human prostate cancers. Whereas absence of hsp27 is a reliable objective marker of early prostatic neoplasia, reexpression of this protein by an individual invasive prostatic carcinoma invariably heralds poor clinical prognosis. Because this protein has been shown to alter the balance between proliferation and apoptosis, understanding the mechanism(s) by which individual hsps regulate intracellular homeostasis may assist in explaining some key processes that occur during evolution of human prostate cancers. We suggest that hsp27 expression provides novel diagnostic and prognostic information on individual patient survival which, if obtained at the time of primary diagnosis, would assist in determining tumor-specific management strategies. Development of techniques to therapeutically modulate hsp27 expression raises the possibility of novel targeted approaches to regulate this homeostatic mechanism, thus allowing better control over tumor cell proliferation and hence patient survival.

Urinary retention in men after total hip arthroplasty.

A prospective study of sixty-four men was conducted before they underwent a total hip arthroplasty to try to identify the factors that are predictive of postoperative urinary retention. Although neither the urological history nor the physical examination provided information that was helpful in accurately identifying the patients who were at risk, those whose peak urinary flow rate was less than seventeen milliliters per second did have a statistically significant likelihood of the development of urinary retention. A system of management that we hope will reduce the incidence of this complication is proposed.

Urodynamic evaluation prior to total hysterectomy: indications and incidence of abnormality.

Although it is recognized that total hysterectomy may be associated with subsequent urinary symptoms, many women are symptomatic prior to operation. However, only objective rather than subjective analysis can provide an accurate assessment of the preoperative state of the lower urinary tract. This study determined the incidence of preoperative, urodynamically-proven, vesicourethral dysfunction in women undergoing total hysterectomy. The incidence of urinary symptoms in 30 women awaiting hysterectomy was assessed and compared with the urodynamic findings. Sixteen (53%) of these patients had preoperative urinary symptoms, although bladder dysfunction was present in only 8 (27%). The presence of marked urinary symptoms in women awaiting hysterectomy warrants preoperative urodynamic investigation to identify any underlying bladder dysfunction.

Protocol of a prospective cohort study of the effect of different methods of drainage of neuropathic bladder on occurrence of symptomatic urinary infection, and adverse events related to the urinary drainage system in spinal cord injury patients.

BACKGROUND: To present a protocol of a prospective, cohort study in which four groups of spinal cord injury (SCI) patients will participate. (Patients with indwelling urethral catheter; patients who perform intermittent catheterisation without wearing a penile sheath; patients who perform intermittent catheterisation and wear penile sheath as well; and patients with penile sheath drainage). OBJECTIVES: (1) What is the incidence of symptomatic urinary infection in men with spinal cord injury who use different types of bladder drainage? (2) Which are predisposing factors for the occurrence of symptomatic urinary infection in men with spinal cord injury who practise different methods of bladder drainage? (3) What is the incidence of catheter and urinary drainage system-related adverse events in the four groups of SCI patients? PATIENTS: The criteria for inclusion are as follow: (1) Male patients with neuropathic bladder due to spinal cord injury, who are registered with the Regional Spinal Injuries Centre, Southport, England. (2) Age: 18 years or above. (3) Patients who are willing to give informed consent for participation in the study. (4) Patients willing to be contacted every two weeks by a staff of the spinal unit for 36 months. (5) Patients who are willing to maintain an accurate record of adverse events related to urinary catheter and urinary drainage system and predisposing factors for the occurrence of symptomatic urinary infection. (6) Patients, who are stabilised in a particular method of bladder drainage, and therefore, unlikely to make a permanent change in the method of bladder drainage (e.g. from penile sheath drainage to the use of long-term indwelling catheter) during a foreseeable future. METHODS: The participants will be observed for a period of 36 months. A staff of the spinal injuries unit will contact the participants by telephone every two weeks on a mutually agreed day and time. The information obtained during this standardised telephonic interview conducted once in two weeks will be entered in a database. When a participant develops symptom(s) suggestive of urinary infection, he will undergo urine and blood tests, and imaging studies of the urinary tract. CONCLUSION: This study will provide information regarding the occurrence of symptomatic urinary infection, predisposing factors for development of urinary infection, and adverse events related to urinary catheter and urinary drainage system in SCI patients using different methods of bladder drainage.

Transverse preputial island flap neo-urethroplasty.

The first account of transverse preputial island flap neo-urethroplasty was given in 1978 by Duckett (unpublished material) from Philadelphia to this association. The procedure, commonly known as the Duckett operation, is for the repair of hypospadias in boys whose urethral defect is too long for them to be treated by meatal advancement and glanduloplasty, also described by Duckett in 1980. These 2 operations leave only a very small number of hypospadiacs with a urethral defect so long that more complicated surgery is needed. Acquired urethral defects can also be repaired using transverse preputial island flap neo-urethroplasty.

Urethral supersensitivity and occult urethral neuropathy.

The phenomenon of postural increases in urethral tone in patients with neuropathic bladder dysfunction has been investigated and, using the technique of simulated alterations in posture, a humoral response of urethral smooth muscle has been demonstrated. Serial measurements of circulating catecholamines have shown that a close correlation exists between the contraction of urethral smooth muscle and the variations in circulating catecholamines brought about as part of cardiovascular homeostasis. Identical urethral responses have been recorded in a group of neurologically intact patients who have urethral outflow obstruction, and it is speculated that these patients may have an occult urethral neuropathy.

The use of sacral reflex latencies in detrusor bladder neck dyssynergia.

Detrusor bladder neck dyssynergia (DBND) is a well recognised cause of bladder outflow obstruction, especially in the younger man. The cause is unknown, and the aim of this study was to determine if any neurological dysfunction is associated with this condition. Twenty-five males with proven DBND had sacral reflex latency studies performed. The conduction latencies indicate that the underlying cause is unrelated to any demonstrable neuropathy. Sacral reflex latencies are not helpful in the investigation of DBND.

Bulbocavernosus reflex latency in the investigation of diabetic impotence.

Impotence in males is a well recognised complication of diabetes mellitus, commonly held to be due to an autonomic neuropathy. The aim of this study was to determine the incidence of periphero-conus neuropathy in diabetic impotence. Nineteen diabetic males seeking treatment for loss of potency had bulbocavernosus reflex latency (BCRL) and sacral reflex latencies (SRLs) performed. The conduction studies indicated that impotence in these cases was associated with peripheral neuropathy in 21% of patients and that BCRL and SRLs are sensitive and useful diagnostic tests.

Bladder dysfunction after simple hysterectomy: urodynamic and neurological evaluation.

Many women presenting with symptoms of bladder dysfunction relate their onset to the operation of simple hysterectomy. This study reviews the urodynamic findings in 126 women who had a simple hysterectomy, of whom 25 also had sacral reflex latencies measured. The results show that 47.0% had detrusor instability, 36.7% had urethral obstruction, and 24.8% stress incontinence. These findings are statistically significant when compared to controls. 80% of the women who underwent measurement of sacral reflex latencies had evidence of nerve conduction abnormality.

The neuropathic urethra.

The hypothesis is advanced that the functional urethral obstruction found in neuropathic states is due, in part at least, to urethral supersensitivity following sympathetic decentralisation. A simple postural test for this condition is described. By its use it has been shown that urethral denervation occurs not only in disorders of the central nervous system but with peripheral damage such as may result from rectal excision and hysterectomy. In some cases with functional urethral obstruction, attributable to suersensitivity of the urethra, no neurological abnormality has been found. These may be examples of localised visceral neuropathy.

Endoscopic biopsy in the diagnosis of peripheral denervation of the bladder.

Endoscopic biopsies of the bladder were stained using a simple neurohistochemical technique to demonstrate the normal cholinergic innervation. The same technique was used on patients in whom a peripheral neuropathic bladder was suspected and clear evidence of denervation obtained. It is suggested that the technique be applied to all cases where peripheral denervation is a possibility to assist in diagnosis and to select cases where long-term urological follow-up is mandatory.

Outflow obstruction in neuropathic bladder dysfunction: the neuropathic urethra.

Urethral pressure profiles were recorded in a series of patients with traumatic lesions of the spinal cord producing vesico-urethral dysfunction. Patients were classified into groups depending upon the relationship of the lesion to the sympathetic outflow to the bladder and urethra from the spinal cord. Using alpha-adrenergic blocking agents, the smooth muscle contribution to the maximum urethral pressure was ascertained in each group and differences in both the configuration of the profile, and the smooth muscle component, were found. Increases in the maximum urethral pressure in response to a change in posture were also investigated, and the extent of the increase found to vary according to the level of the spinal lesion in respect of the sympathetic outflow, and with the integrity of the sacral cholinergic reflex arcs. The hypothesis that these changes may be due to urethral "decentralisation supersensitivity" from alterations in circulating catecholamine levels is suggested.

Primary vesical sensory urgency. A clinical trial of bromocriptine.

A randomised double blind crossover trial of Bromocriptine against an inert placebo was performed in 14 patients with primary sensory urgency. Bromocriptine was found to have no therapeutic advantage for these patients and the possible explanations for this finding are discussed.

The effects of simple hysterectomy on vesicourethral function.

Many women who present with symptoms of bladder dysfunction relate the onset to the operation of simple hysterectomy. A group of 42 women undergoing simple hysterectomy was studied prospectively. Urinary symptoms, urodynamic findings and sacral reflex latencies (SRLs) were assessed pre- and post-operatively. After hysterectomy the incidence of urinary symptoms increased from 58.3 to 75.0%. Vesicourethral dysfunction was altered in 30.6% of patients, 72.7% of whom had evidence of pelvic neuropathy as detected by SRLs. The results show that simple hysterectomy is associated with a significant incidence of post-operative vesicourethral dysfunction and that there is an identifiable neurological abnormality incurred at operation which is pertinent to the subsequent disordered voiding.

Chronic urinary retention--a sensory problem?

Factors which predispose some men with benign prostatic hyperplasia to chronic urinary retention whilst others develop acute retention are not understood. In order to assess whether there is an occult neuropathy associated with chronic retention, neurophysiological measurements were used to test the integrity of the lower urinary tract nerve supply. A series of 22 male patients with chronic urinary retention secondary to prostatic hyperplasia underwent sacral reflex latency measurement; 73% demonstrated a sensory suprasacral abnormality with intact spinal reflex arcs. These results suggest that although the sacral reflex pathways are intact, there is a sensory/proprioceptive abnormality in the higher neurological centres which may be an adaptive mechanism to the presence of bladder outflow obstruction.

The management of upper urinary tract calculi in spinal cord damaged patients.

The management of upper urinary tract calculi in 49 patients in the Mersey Regional Spinal Injuries Centre was reviewed retrospectively. Morbidity in nine patients was increased by either delay in operative intervention (5 cases) or inadequate follow up evaluation (4 cases). Earlier active treatment using modern endourological techniques and lithotripter technology is encouraged. A clinical algorithm incorporating these new techniques is shown.

The urological management of spinal cord damaged patients: a clinical algorithm.

A scheme for the management of the common urological presentations encountered in spinal cord damaged patients is provided in flow chart form. The diagrams indicate how urological investigations can be used to greatest effect. A simple computer programme based on these charts is available.

Urodynamic evaluation of lower urinary tract function in relation to total hysterectomy.

Although many women relate the onset of urinary symptoms to the operation of simple hysterectomy, many also have symptoms prior to surgery. Prospective study is therefore the most valid method of objective analysis of the effects of this operation upon micturition. To determine whether total hysterectomy is associated with increased postoperative vesicourethral abnormality, the incidences of urinary symptoms and urodynamic abnormality were assessed pre and postoperatively in 36 women undergoing hysterectomy. Preoperative symptoms were present in 58.3%, although urodynamically proven dysfunction was found in only 38.9%. After hysterectomy, 75% of women were symptomatic with a further 30.6% developing a urodynamic abnormality. The operation of total (simple) hysterectomy is associated with a significant increase in the subjective and objective incidence of vesicourethral dysfunction.

Bladder transection--a functional, neurophysiological, neuropharmacological and neuroanatomical study.

Experimental models to represent the surgical methods of bladder transection in humans were performed on dogs and rabbits. The effects on vesical neurophysiology were studied by cystometry with bethanechol supersensitivity testing; by in vitro pharmacological responsiveness; by determination of autonomic receptor densities using radioligand binding and by autonomic neurohistochemical staining. Analysis revealed that transection with or without neurovascular preservation resulted in an alpha-adrenergic denervation and cholinergic decentralisation. A comparison with the surgical models is presented and proposed mechanisms of action are discussed in relation to the experimental results.