Hajime Morita

Is suprapubic cystostomy an optimal urinary management in high quadriplegics?. A comparative study of suprapubic cystostomy and clean intermittent catheterization.

Introduction: Long–term outcome of spinal cord injury (SCI) patients was compared between those managed by suprapubic cystostomy (SPC) and clean intermittent catheterization (CIC) with particular emphasis on an incidence of urinary tract complications and patients perception for urinary management.Materials and Methods: The study comprised 61 SCI patients; 34 patients managed with SPC (group A), while 27 with CIC (group B). After stabilization of their condition, all were followed annually on an outpatient basis with clinical history, urinalysis, urinary imaging and renal function studies. Mean follow–up periods were 8.6 and 9.9 years for groups A and B, respectively. Between groups, a comparative study was performed on the incidence of urinary complications such as renal dysfunction, hydronephrosis, vesicoureteral reflux, symptomatic genitourinary infection and urinary stone. Satisfaction with urinary management was also estimated using the questionnaires during follow–up.Results: Renal dysfunction, hydronephrosis and vesicoureteral reflux were not found in either group. Symptomatic genitourinary infection was seen in 4 (12%) of group A and 7 (26%) of group B, respectively. The incidence of renal stone was 3 (9%) in group A and 1 (4%) in group B. A significant difference was not found between two groups in these urinary complications. On the contrary, bladder stone was seen more frequently in group A (65%) than in group B (30%) with a significant difference (p<0.001). The degrees of incontinence, bother score of daily activities, and overall satisfaction showed no significant difference between the two groups.Conclusion: Except for bladder stones, SPC is a valuable option of urinary management for quadriplegic patients, the results of which were comparable to paraplegic SCI patients managed with CIC.

Vesicourethral function in diabetic patients: association of abnormal nerve conduction velocity with vesicourethral dysfunction.

This study was undertaken to examine diabetic vesicourethral dysfunction in association with nerve conduction velocity. Uroflowmetry, water cystometry, International Prostate Symptom Score (IPSS), and nerve conduction velocity were analyzed in 29 diabetic patients (21 men and eight women; a mean age, 58.0 years). Nerve conduction velocity was measured for sensory nerve conduction velocity (SCV) of the sural nerve and motor nerve conduction velocity (MCV) of the peroneal nerve. Normal voiding was defined as continuous flow at the normal flow rate and residual urine <50 mL. Results of uroflowmetry and cystometry were compared with those of nerve conduction velocity. Eleven of 29 patients (38%) had voiding dysfunction. A vesical denervation supersensitivity test was negative in all patients. The mean IPSS was not significant different between patients with or without voiding dysfunction. Incidence of bladder volume at first desire to void >300 mL and maximum bladder capacity >500 mL were significantly higher in patients with abnormal SCV than those with normal SCV (P < 0.03 and 0.001, respectively). Eleven of 16 patients with abnormal MCV showed voiding dysfunction, whereas all patients with normal MCV showed normal voiding (P < 0.001). These results suggest that lower urinary tract symptoms alone cannot predict diabetic vesicourethral dysfunction and that diabetic vesicourethral dysfunction is highly correlated with abnormal nerve conduction velocity. Neurourol. Urodynam. 18:639–645, 1999.

Single Ectopic Ureter

We report on 17 female and 4 male patients with single ectopic ureters, 9 of whom also had vaginal ectopic ureters. The clinicopathological features and surgical management are presented, with particular emphasis on the associated renal dysplasia and the complete excision of the ectopic ureteral stump. Although single ureteral ectopia with drainage to the vagina is rare in the English literature the condition is common in Japan.

Radical Transurethral Resection of the Prostate in Male Paraplegics Revisited: Further Clinical Experience and Urodynamic Considerations for its Effectiveness

We report our experience with radical transurethral resection of the prostate performed on 89 male spinal cord injury subjects. The over-all success rate of modified sphincterotomy was 90 per cent, although there was a 14 per cent recurrence rate with time. Urodynamically, success was characterized by a statistically significant reduction in the degree of detrusor-sphincter dyssynergia, an increase in vesical compliance and a reduction in detrusor hyperreflexia. These results suggest an effect on the distal sphincteric area by the adrenergic system in the genesis of detrusor-sphincter dyssynergia. It is suggested that radical transurethral resection of the prostate exerts this effect via a surgical sympathectomy, while continence is preserved by the activity of the untouched external urethral sphincter.

Neurogenic urethra: clinical relevance of isolated neuropathic dysfunction of the urethra, and the denervation supersensitivity of the urethra revisited.

Our clinical experience on isolated neuropathic dysfunction of the urethra is presented. By discussing the urodynamic findings in neurogenic urethra, wherein the denervation supersensitivity to alpha-adrenergic stimulation in the absence of vesical denervation was a common denominator, some insight into the modern concept of motor innervation of the urethra was attempted. Our data are supportive of the current dogma implicating a significant sympathetic contribution to both autonomic and somatomotor innervation of the urethra.

Detection of missing vesicoureteral reflux with bethanechol chloride-aided voiding cystourethrography.

Experience in the detection of absent vesicoureteral reflux with bethanechol-aided voiding cystourethrography is presented. The detection rate with conventional contrast-enhanced voiding cystourethrography among 9 study subjects, in whom vesicoureteral reflux otherwise was highly suspected from accompanying clinical, urographic and endoscopic features, and in whom it was absent contralaterally or bilaterally, was improved from 33 per cent (only 3 of 9 patients were positive for reflux) to 100 per cent (all 9 were proved to have vesicoureteral reflux) after bethanechol stimulation. Some representative cases are presented and the mechanisms of inducing vesicoureteral reflux with bethanechol are discussed as well as its clinical relevance. Bethanechol-aided voiding cystourethrography is suggested as a highly sensitive method to detect absent vesicoureteral reflux.

URINARY CONTROL AFTER RADICAL TRANSURETHRAL RESECTION OF THE PROSTATE IN MALE PARAPLEGICS: URODYNAMIC EVALUATION OF ITS EFFECTIVENESS IN RELIEVING INCONTINENCE

We report our investigation of urinary incontinence in 51 male paraplegics with radical transurethral resection of the prostate. Pre‐operatively, 28 cases (55.9%) had moderate or severe incontinence, which persisted post‐operatively only in 21 cases (41.2%) and was less severe. Post‐operatively, bladder compliance was improved from 22.1 22.6 ml/cmH2O to 36.4 38.5 ml/cmH2O, and the maximum pressure of uninhibited detrusor contraction was reduced from 40.2 21.5 cmHzO to 18.3 19.0 cmH2O. These significant improvements are thought to contribute to the relief of urinary incontinence, regardless of the reduction in maximum urethral closure pressure.

Experience of the parenchyma saving procedure in the surgical management of renal cell carcinoma

The result of renal conserving procedures for the surgical management of renal cell carcinoma experienced in 10 patients was reported. All except two were afflicted with tumor involvement in both kidneys (four cases) or in the solitary functioning kidney (four cases). The tumor stage was I in 8 and IV in 2 patients. One of the stage IV patients died of metastatic disease 8 months postoperatively. Of the 9 patients, 8 remained free of cancer in the follow-up period, while one who received an enucleative surgery and whose pseudocapsule of the tumor was missing had a local recurrence. Four of the 5 tumors having no pseudocapsule or having an invasion in the pseudocapsule were grade 2 or 3. The renal conserving surgery is believed to yield an excellent control in low grade and low stage tumors. Partial nephrectomy, rather than simple enucleation, remains to be a preferred surgical treatment in parenchyma-sparing operation, although the enucleative surgery may have a good indication for multiple and central encapsulated tumors.