Ian Walsh

Artificial urinary sphincter implantation in the irradiated patient: safety, efficacy and satisfaction

Objective To compare the long‐term outcome of artificial urinary sphincter (AUS) implantation in patients after prostatectomy, with and with no history of previous irradiation.

Urethral Atrophy After Artificial Urinary Sphincter Placement: Is Cuff Downsizing Effective?

PURPOSE We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy. MATERIALS AND METHODS We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire. RESULTS Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, inhibition) score decreased from 8.2 to 2.4. Patient satisfaction increased from 15% to 80% after cuff downsizing. In 1 patient an infected cuff required complete removal of the device. CONCLUSIONS Patient satisfaction and continence parameters improved after cuff downsizing. We believe that this technique is a simple and effective method of restoring continence after urethral atrophy.

The BTA stat test: a tumor marker for the detection of upper tract transitional cell carcinoma

OBJECTIVES To conduct a prospective evaluation to determine the utility of the BTA stat test in the detection of upper tract transitional cell carcinoma (UTTCC). Monitoring for UTTCC currently relies on invasive procedures such as upper tract imaging, ureteral washing cytology (UWC) and/or ureteroscopy, or voided urine cytology (VUC). The BTA stat test is a sensitive qualitative immunoassay that detects human complement factor H-related protein in voided urine. METHODS A total of 81 patients participated, 27 with histopathologically confirmed UTTCC, 26 with upper tract calculi, and 28 with microscopic hematuria but no evidence of urologic disease. Voided specimens collected before surgery or treatment were tested with the BTA stat test and VUC. UWC was performed in specimens collected by a ureteral catheter. RESULTS The BTA stat test was significantly more sensitive and specific than VUC or UWC. The overall sensitivity for each was 82%, 11%, and 48%; the specificity was 89%, 54%, and 33%. The positive predictive value for the BTA stat test was 79% and the negative predictive value was 91%, both the highest of the three tests. CONCLUSIONS The BTA stat test was superior to VUC and UWC in the detection of UTTCC. These results may support the adoption of a less aggressive follow-up policy when monitoring for UTTCC when the BTA stat result is negative. If cystoscopy is negative and the BTA stat test is positive, upper tract investigations should be expedited and, if the bladder is in place, bladder biopsies performed.

Cadaveric fascia lata pubovaginal slings: early results on safety, efficacy and patient satisfaction

Objective  To prospectively evaluate and quantify the efficacy of cadaveric fascia lata (CFL) as an allograft material in pubovaginal sling placement to treat stress urinary incontinence (SUI).

Non-invasive antidromic neurostimulation: a simple effective method for improving bladder storage.

Patients with intractably diminished bladder storage function are encountered frequently by neurourologists, occasionally requiring reconstructive surgery for appropriate resolution. Although sacral neuromodulation is a recognized effective therapeutic modality, present techniques are technically demanding, invasive, and expensive. This study investigated the effect of non‐invasive third sacral nerve (S3) stimulation on bladder activity during filling cystometry. One hundred forty‐six patients underwent standard urodynamic filling cystometry that was then immmediately repeated. Patients in the study group (n = 74) received antidromic transcutaneous sacral neurostimulation during the second fill and the control group (n = 72) underwent a second fill without neurostimulation. A statistically significant increase in bladder storage capacity without a corresponding rise in detrusor pressure was observed in the neurostimulated patients. This improvement in functional capacity is an encouraging finding that further supports the use of this non‐invasive treatment modality in clinical practice. Neurourol. Urodynam. 20:73–84, 2001.

Digital necrosis with Ogilvie’s syndrome

A 76 year old retired fisherman presented with a progressive four week history of cold, painful, blue fingers. Systematic enquiry was unremarkable apart from generalised lethargy over the preceding six weeks. He had osteoarthritis of his left hip and had taken indomethacin 25 mg thrice daily for five years. He was an ex-smoker of 20 cigarettes/day for 40 years. On examination he was apyrexic. There was severe ischaemia of both hands with gangrene and necrosis of the fingertips (fig 1). Both feet were cyanosed, but there was no overt ischaemia or necrosis. All peripheral pulses were palpable with a blood pressure in both arms of 160/90. There were no large vessel bruits or cardiac murmurs. Abdominal distension was noted but there was no tenderness or organomegaly. His fundi were normal. The remainder of the physical examination was unremarkable. Figure 1 Severe digital ischaemia and necrosis of the patient’s hands at presentation. Laboratory investigations revealed a hypochromic, normocytic anaemia with a haemoglobin of 9.4 g/dl and a white cell count of 19.1. × 109 with a neutrophilia. The erythrocyte sedimentation rate (Westergren) was 133 mm/1st h with a C reactive protein of 180 mg/l (normal range <10 mg/l). Urine analysis revealed 2+ protein, 3+ blood and granular casts but no red cell casts. Urine and blood cultures were sterile. The urea was 19.7 mmol/l and the serum creatinine 180 μmol/l with a creatinine clearance of 43.6 ml/min and a urinary total protein of 0.13 …

Urethral stents for detrusor sphincter dyssynergia

failure to fully eliminate residual urine, the potential for significant haemorrhage and the need to repeat the procedure in up to 25% of patients [2]. Patients are also reliant upon condom-catheter drainage and less than half of patients continue with this drainage method in the long term. An alternative, less-invasive method is sphincter ablation by direct injection of Botulinum toxin. This provides only temporary relief, and repeat injections are necessary every couple of months. Balloon dilatation is another alternative, but this is restricted by recurrent obstruction and excessive bleeding [3].

Intra‐testicular varicocele presenting as acute scrotum

The term varicocele describes a dilated, tortuous and elongated pampiniform plexus of veins, which is well known in relation to the spermatic cord. Recently varicocele has also been observed inside the testis, and this new entity is known as intra‐testicular varicocele. We present a case of intra‐testicular varicocele presenting as acute scrotum and discuss the management issues.

A case of repetitive penile fracture: an increasingly observed phenomenon.

A 41-year-old Caucasian man presented to the emergency department after suffering a penile fracture during alcoholfuelled coitus. This was his second penile fracture in nine years. He described the pathognomonic ‘pop’, followed by acute pain and rapid detumescence, from an extreme downward bend of his erect penis while his partner was sat ‘cow-girl’ on top of him. On examination, his penis was grossly engorged and deviating to the right by a large haematoma at its base. Subsequent emergency exploration via sub-coronal circumferential de-gloving allowed evacuation of the haematoma, revealing a proximal lateral split of the left corpus cavernosum, which was sutured to create a watertight seal. It only transpired after reviewing medical records that this repeat fracture had occurred distally to the original fracture, which ruptured the ventral aspect of the right contralateral corpus, following rear-entry ‘doggy-style’ coitus. There are nine documented cases of a repetitive penile fracture, seven of which occur on the ipsilateral corpus cavernosum, with only two identifying a second contralateral fracture.1–9 It would imply that a previously fractured penis is prone to fracture again, with ipsilateral reoccurrences suggesting a weakening at, or around, the fibrotic scar. However, contralateral reoccurrences would infer an alternative mechanism of fracture. A non-elastic fibrous scar could create discrepancies in the length of the two erect coronal bodies, as tethering around the scar can cause stretching of the contralateral fascia, leaving it prone to fracture, and at lesser intra-cavernous pressures that necessitate a rupture. Postoperative long-term complications, such as erectile dysfunction and dyspareunia, should now also recognise repeat fracture as long-term sequelae. A similar fracture phenomenon has been reported in cases of Peyronie’s disease, where penile curvature by tunica-anchoring plagues can risk rupture during traumatic intercourse. In addition to fracture repair, plication surgery to correct angulation is also performed.10 Repetitive fracture may also hint at a structural histological abnormality. De Rose et al. identified chronic inflammatory changes in cases of penile fracture that included fibrosclerosis and lymphocytic infiltration, which appeared to weaken the corpora cavernosa, and thus predispose the penis to fracture.11 Although tissue sampling was not undertaken, in reflection it would have been appropriate, as any possible histological abnormality may have uncovered a co-existing systemic inflammatory process. Most at-risk sexual positions for blunt penile trauma involve the partner on top, and rear-entry ‘doggy-style’ coitus, the two positions relevant to this case. On both occasions, the gentleman had also consumed alcohol to excess, chancing more vigorous intercourse but also coital incoordination, thus increasing his risk of fracture. Five months post-surgery, he was achieving erections, having intercourse and ejaculating normally, albeit with some anxiety. Surgical repair of all penile fractures should ensure corpora of equal length, by means of artificial erection testing, to minimise discrepancy and reduce the risk of repeat contralateral fracture. Tissue sampling is also recommended to identify any causal histology and possible coinciding quiescent systemic disease. Furthermore, patient education after fracture should include avoidance of vigorous intercourse when under the influence of alcohol, and awareness that repetitive fracture is now recognised long-term sequelae. A case of repetitive penile fracture: an increasingly observed phenomenon

Arts in health: considering language from an educational perspective in the United States

Abstract Background: There has been tremendous progress linking the arts to health over the past five decades in the United States. An academic discipline has been clearly established through the development of programs at accredited universities, a growing body of research and dedicated field journals. However, significant inconsistencies in the use of language to reference the discipline pose challenges for practitioners, educators, policy-makers, service users and the public, and may impede progress. Methods: This descriptive study investigated the language used to reference the discipline informed by literature review, technical examination of language, a field survey and round-table dialog among educators. Results: The literature review revealed “arts and health” as the most common term used, which also was the preferred term for the greatest number of survey respondents (26%), followed by “arts, health and well-being” (22%) and “arts in health” (21%), confirming a general lack of consensus. Technical examination of language identified certain terms or phases as problematic. Dialog among round-table participants yielded the recommendation for “arts in health” as the term that, for educational purposes, may best describe the overarching discipline and be inclusive of both health care and community-based practices. Conclusions: A recommendation is made for use of the term “arts in health” to reference the discipline in educational programs in the U.S.