Alexander Schultz

SOMATIC FUNCTION, MENTAL HEALTH AND PSYCHOSOCIAL FUNCTIONING IN 22 ADOLESCENTS WITH BLADDER EXSTROPHY AND EPISPADIAS

PURPOSE We report the long-term somatic outcome, mental health and psychosocial adjustment in adolescents with bladder exstrophy and epispadias. MATERIALS AND METHODS A total of 22 adolescents 11 to 20 years old (median age 14.5), including 19 with bladder exstrophy and 3 with epispadias, were assessed for urogenital status, stoma, renal and bowel function, anorectal physiology, mental health and psychosocial functioning by physical examinations, semistructured interviews and standardized questionnaires. The parents of 21 patients were interviewed and completed questionnaires. Information was also obtained on control groups. RESULTS Of the 22 patients 9 (41%) had no urinary diversion and were urinary incontinent, 6 (27%) had persistent fecal staining and anal canal pressures that were lower than the controls, 10 (59%) were dissatisfied with the penile appearance and 11 (50%) met the criteria for psychiatric diagnoses. The main predictors of mental health were parental warmth and patient genital appraisal in the 11 to 14-year age group, and parental warmth and urinary continence function in the 15 to 20-year age group. Psychosocial dysfunction was predicted by fecal incontinence in the younger group and worries about future sexual relationships in the older group. CONCLUSIONS The present multimodal outcome study revealed that adolescents with bladder exstrophy and epispadias had significant physical and mental problems. Genital malformation, and urinary and fecal incontinence may have a negative impact on mental health and psychosocial functioning. Our findings emphasize the need to include psychosocial experts on health care teams to reveal the amount of distress caused by these anomalies and to offer psychosocial support.

Perforation of continent urinary reservoirs. Scandinavian experience.

In a questionnaire survey of urological departments in Sweden, Denmark, Finland and Norway, 20 episodes of perforation of continent urinary pouches were found to have occurred in 18 patients, representing an incidence of 1.5%. This complication occurred with ileal as well as colonic segments, without predilection. In one case there was perforation of an appendiceal outlet. Noticeable findings were (a) a long delay (median 10h) to treatment and (b) that investigational procedures such as enterocystography and enterocystoscopy were not commonly employed. Treatment of this potentially lethal complication was by oversewing the perforation, and there were no subsequent major complications. This complication should be strongly suspected if a patient with continent urinary reconstruction presents with acute abdominal pain.

Mental health, psychosocial functioning, and quality of life in patients with bladder exstrophy and epispadias — an overview

Abstract Although there has been only limited clinical research on mental or psychosocial implications in patients with bladder exstrophy and epispadias, questions have been raised as to whether their life is of such questionable quality that a termination of pregnancy should be considered. A systematic overview of outcome studies published over the past three decades was carried out. In all, 1208 abstracts and 52 papers were read; only 10 (0.8%) papers focused on the mental or psychosocial outcome, but with diverse findings. However, most of the studies suffered from serious methodological deficiencies. Physical, mental, and psychosocial problems revealed in studies with reliable and valid instruments have clinical implications and underline the need for the further development of surgical and psychosocial interventions. Multicenter studies with a multimodal, prospective, and longitudinal design, based on semistructured interviews and specific questionnaires related to the disorder, are appropriate.

Long-term experience with surgical treatment of selected patients with bladder pain syndrome/interstitial cystitis

Abstract Objective. The role of major surgery in patients with bladder pain syndrome/interstitial cystitis (BPS/IC) is not fully established. This report presents a single-institution experience with major surgery in patients with disabling BPS/IC where conservative treatment had failed. Material and methods. Forty-one patients (34 women, seven men) with BPS/IC refractory to conservative treatment underwent major surgery from 1983 to 2004. Surgical approach was determined on a case-by-case basis. Postoperative pain and satisfaction were assessed by a questionnaire. Results. Cystectomy was the primary procedure in five patients. The remaining 36 patients were primarily operated on with subtotal cystectomy and bladder augmentation (n = 16) or supravesical urinary diversion with intact bladder (n = 20). Thirteen of these patients were later operated on with cystectomy due to persisting pain 12 (6–146) months after the primary procedure. The questionnaire was answered by 38 of 41 patients after a median follow-up of 66 (6–238) months. In total, 28 patients (74%) were free of pain, and 26 patients (68%) were satisfied with the end result. There was no difference in reported pain between cystectomized and non-cystectomized patients. When comparing patients who reported pain at follow-up with those who did not report pain, preoperative length of symptoms was significantly increased, with 12.1 compared to 5.4 years (p = 0.02). Conclusions. Major surgery is associated with good symptom relief in strictly selected patients with disabling BPS/IC, where conservative treatment has failed. Extended preoperative duration of symptoms may be a predictor for persisting pain after major surgery for BPS/IC.

Metabolic evaluation and medical management of upper urinary tract stone disease. Guidelines from the Scandinavian Cooperative Group for Urinary Stones.

A set of simple guidelines for metabolic evaluation and medical/dietary management of patients with urolithiasis is presented. The evaluation scheme is based on the documented risk factors in the Nordic area and the results of controlled clinical trials, and takes its basis in the severity of the stone disease in the individual stone patient. The initial evaluation in all patients aims at diagnosing conditions with a definitive metabolic, infectious or anatomical/functional cause of stone formation (MIAF urolithiasis). Patients with MIAF urolithiasis are treated according to the nature of the underlying disease. Having excluded/diagnosed MIAF urolithiasis, patients with idiopathic calcium nephrolithiasis remain, and in this group, which comprises approximately 85% of the total stone population in the Scandinavian region, only those with a complicated stone disease are subjected to additional evaluation, which aims at identifying underlying pathophysiological derangements for which medical therapy has been proven to be effective in controlled clinical trials.

The rationale behind recommendations for follow-up after urinary diversion: An evidence-based approach

Departments of Urology, Haukeland University Hospital, Bergen, Norway, Aarhus University Hospital, Skejby Sygehus, Aarhus, Denmark, Sahlgrenska University Hospital, Göteborg, Sweden, Landspitali University Hospital, Reykjavik, Iceland, University Hospital, Lund University, Lund, Sweden, Oulu University Hospital, Oulu, Finland, Rikshospitalet University Hospital, Oslo, Norway, State University Hospital, Copenhagen, Denmark, and Kuopio University Hospital, Kuopio, Finland

A New System for Descriptive Classification of Stones in the Upper Urinary Tract

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Severe postprostatectomy incontinence: Is there an association between preoperative urodynamic findings and outcome of incontinence surgery?

Abstract Objective.This study investigated urodynamic findings in prostate cancer patients with self-reported persistent severe postprostatectomy urinary incontinence (PPI) as well as the outcome of incontinence surgery. The main aim was to evaluate the ability of preoperative urodynamic dysfunctions to predict the outcome of incontinence surgery. The hypothesis was that preoperative bladder dysfunction was predictive of an unsuccessful surgical outcome. Materials and methods. Based on patient-reported adverse effects after radical prostatectomy (RP) in 2005–2009, 94 men with persistent severe PPI were invited in 2011 to a clinical examination including urodynamics. When indicated, surgery for PPI was offered, and by January 2014, 46 patients had been operated on with either an artificial urinary sphincter or a sling. The outcome of PPI surgery was evaluated with a follow-up questionnaire. Successful outcome was defined in two ways: patient-reported satisfaction and using one or fewer pads/day. Results.Of the 94 men with severe PPI more than 12 months after RP, 76 patients (81% response rate) met for clinical examination. Among them, 99% had intrinsic sphincter deficiency, in 67% coexisting with urodynamic bladder dysfunction. The presence of preoperative bladder dysfunction was not predictive of the outcome of PPI surgery. Preoperative use of fewer pads, less severe PPI, and a longer interval between RP and PPI surgery were associated with the successful outcome of one or fewer pads/day. Longer duration from RP to PPI surgery was the only preoperative factor associated with the successful outcome of satisfaction. Conclusions.The hypothesis was not supported as the presence of preoperative urodynamic bladder dysfunction was not predictive of the outcome of PPI surgery in this study.

Reconstructive urology in the nordic countries--a hospital questionnaire survey.

A hospital survey of adult reconstructive urologic surgery in the Nordic countries is presented. The response rate was 80% and included most general hospitals and university clinics. Despite similarities between the healthcare systems of the various countries several differences were found. Cystectomy was performed in a large number of institutions in all countries except Denmark. The annual number of orthotopic bladder substitutions per institution was calculated as three to four (range of medians for each country) and the number of continent cutaneous diversions as two to seven. Open urethral procedures were performed more frequently in Sweden than in the other countries. Surgery for penile curvature and implantation of three-component prostheses for erectile dysfunction was more commonly performed in Denmark and Iceland compared to Sweden.A hospital survey of adult reconstructive urologic surgery in the Nordic countries is presented. The response rate was 80% and included most general hospitals and university clinics. Despite similarities between the healthcare systems of the various countries several differences were found. Cystectomy was performed in a large number of institutions in all countries except Denmark. The annual number of orthotopic bladder substitutions per institution was calculated as three to four (range of medians for each country) and the number of continent cutaneous diversions as two to seven. Open urethral procedures were performed more frequently in Sweden than in the other countries. Surgery for penile curvature and implantation of threecomponent prostheses for erectile dysfunction was more commonly performed in Denmark and Iceland compared to Sweden.

Urostomy and health-related quality of life in patients with lower urinary tract dysfunction

Abstract Objective.Urinary diversion may be an option in patients with disabling lower urinary tract dysfunction (DLUTD), refractory to conservative and minor invasive treatment. The aim of this study was to evaluate whether urostomy improves quality of life and cost of surgery, in terms of complications, loss of kidney function and hospital stay, in these patients. Material and methods. This prospective study included 52 consecutive patients (nine men and 43 women) with various benign disorders. Twenty-six patients received an ileal conduit and 26 a continent cutaneous diversion. The patients completed the general health-related quality of life instrument WHOQOL-BREF and a urinary problem-specific quality of life instrument preoperatively and 6 and 12 months after surgery. Length of hospital stay and complications were registered. Intravenous urography and determination of glomerular filtration rate (GFR) were performed preoperatively and 12 months postoperatively. Results.Disease-specific and health-related quality of life improved significantly (p < 0.0005 and p < 0.05) in all domains except for social relationship, from preoperative to 12 months after surgery. There was no difference in improvement between patients with continent and those with incontinent diversion. Mean hospital stay was 14 days. Early and late complications required open surgery in 12 patients (23%). GFR was unchanged postoperatively. Conclusions.Urinary diversion improves health-related and disease-specific quality of life in patients with DLUTD refractory to conservative and minor invasive treatments. The burden of surgery is acceptable. Urinary diversion could be recommended more often in such patients.