Vincent Tse

THE APPLICATION OF ULTRASTRUCTURAL STUDIES IN THE DIAGNOSIS OF BLADDER DYSFUNCTION IN A CLINICAL SETTING

PURPOSE We examine the ultrastructural changes reported to be present in dysfunctional bladders and determine whether they can be used as a predictor of urodynamic diagnosis in a clinical setting. MATERIALS AND METHODS Subjects who required urodynamic diagnosis and cystoscopy as part of clinical management were recruited for this study. After urodynamic diagnosis cases were classified into 1 of 5 dysfunction groups as normal bladder outflow obstruction, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability. A detrusor muscle biopsy was taken from the lateral wall of the bladder at cystoscopy for subsequent electron microscopy. RESULTS Of the 27 cases 6 were normal, 9 had bladder outflow obstruction and detrusor instability, 8 had pure detrusor instability and 4 had idiopathic sensory urgency. The obstructed group showed the myohypertrophy pattern previously reported. In contrast to previous reports, abnormal junctions were found in all patients. For each patient the ratios of abnormal-to-normal junctions were calculated. Mean and standard error ratios were 1.1+/-0.1, 2.7+/-0.2, 6.1+/-1.2, 13.3+/-4.4 for normal, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability, respectively (p = 0.0003, 0.0042 and 0.04). CONCLUSIONS There are distinct morphological changes in the detrusor associated with bladder dysfunction. The ratio of abnormal-to-normal junctions is a novel measurement and can be used to predict urodynamic dysfunction. Ultrastructural studies may be useful as an adjunct in the diagnosis of bladder dysfunction.

The Female Patient

A 45-year-old healthy female presents with 3 months of worsening urinary urgency, frequency, and urgency incontinence. Physical examination was unremarkable.

Nephrogenic adenoma of the bladder in renal transplant and non-renal transplant patients: A review of 22 cases

OBJECTIVES To review diagnoses of nephrogenic adenoma and in particular to evaluate its association with transitional cell carcinoma (TCC) of the bladder and its relationship to renal transplantation. METHODS A retrospective review of 22 cases of nephrogenic adenoma (NA) diagnosed between 1989 and 1996 was conducted, 7 of which were in renal transplant patients. Data collected in each case included demographic details, predisposing factors, associated urologic pathology, mode of presentation, cystoscopic finding, management, and follow-up. RESULTS There was a 3:1 predominance of men. Mean follow-up was 21.4 months (range 3 to 50). Six patients (27%) had one or more recurrences. All 22 patients had some form of previous bladder insult or surgery, including recurrent urine infections, urinary tract instrumentation, placement of ureteric stents, cystodiathermy, and open bladder surgery. Six cases were associated with TCC of the bladder, of which 4 had NA lesions directly over or close to the site of previous fulguration. In 4 patients, there was a temporal relationship between the administration of intravesical doxorubicin hydrochloride or bacille Calmette-Guérin (BCG) and the onset of NA lesions. One case was associated with an inverted papilloma that had not been described before. In 7 renal transplant cases, 3 lesions were found contralateral to the side of the ureterovesical anastomosis. All 22 cases were benign histologically, but one NA was found within a low-grade baldder TCC. Nineteen cases were followed up regularly with no malignant transformation. Three patients were lost to follow-up. CONCLUSIONS This study has demonstrated an association between NA and bladder cancer. Patients with NA, especially those treated with intravesical chemotherapy or BCG, should have regular cystoscopies. Fulguration or transurethral resection appear to be sufficient treatment. No renal transplant patients had vesical TCC and NA simultaneously. Neither immunosuppression nor ureterovesical anastomosis appeared to be a significant predisposing factor in the transplant patients.

Incontinence after prostatectomy: the artificial urinary sphincter.

idea of an artificial device to improve urethral resistance. In 1947, Foley was the first to describe an AUS which resembled a sphygmomanometer, consisting of a periurethral inflatable cuff which was connected to a detachable pump carried in the patient’s pocket [5]. As it was an external device and not made of inert material, success was minimal and its popularity quickly dwindled. In June 1972, Scott implanted his new device in a 36-year-old woman with myelodysplasia and started the modern era of AUS implantation [6]. This sparked innovators to design other types of AUS, e.g. the Kaufman passive silicone gel prosthesis (1973) and the Rosen sphincter (1975), comprising a three-pronged rubber clamp fitted across the urethra, thus sandwiching it when the middle arm is inflated [7]. Their success rates were low, as they were volumedependent systems. Craggs [8] presented the first pressure-regulated sphincter, claiming better success than the volume-dependent systems.

Pathophysiology and animal modeling of underactive bladder

AbstractWhile the symptomology of underactive bladder (UAB) may imply a primary dysfunction of the detrusor muscle, insights into pathophysiology indicate that both myogenic and neurogenic mechanisms need to be considered. Due to lack of proper animal models, the current understanding of the UAB pathophysiology is limited, and much of what is known about the clinical etiology of the condition has been derived from epidemiological data. We hereby review current state of the art in the understanding of the pathophysiology of and animal models used to study the UAB.

Diagnosing detrusor sphincter dyssynergia in the neurological patient.

•  Detrusor sphincter dyssynergia (DSD) is variant of neurogenic bladder dysfunction caused by suprasacral neurological abnormalities and may be associated with serious complications if unrecognised. •  This paper focuses on the clinical features as well as challenges and limitations in the diagnosis of DSD.

Transurethral Prostate Resection in Patients with Hypocontractile Detrusor—What is the Predictive Value of Ultrastructural Detrusor Changes?

PURPOSE Men with detrusor failure and chronic urinary retention have a lower voiding success rate and higher postoperative morbidity following transurethral prostatectomy than those with bladder outlet obstruction. Current investigations, including urodynamics, may be unable to predict the response to surgical treatment. We identified ultrastructural features on detrusor biopsy that correlated with the postoperative voiding outcome in patients with a hypocontractile detrusor undergoing transurethral prostatectomy. MATERIALS AND METHODS Detrusor biopsies were obtained from 17 patients with urodynamic evidence of bladder outlet obstruction or a hypocontractile detrusor undergoing transurethral prostatectomy and from 5 controls. Specimens were examined by transmission electron microscopy. Ten individual detrusor ultrastructural features were analyzed. Findings were compared with preoperative and postoperative clinical parameters. RESULTS Failure to void after transurethral prostatectomy was significantly associated with the ultrastructural features of variation in muscle cell size, muscle cell shape, collagenosis and abnormal fascicles. These 4 features were significantly associated with each other, defining a distinctive pattern of detrusor failure. For transurethral prostatectomy failure the sensitivity, specificity, and positive and negative predictive values of all 4 features together were 60%, 91%, 75% and 84%, respectively. Three or 4 features on detrusor biopsy predicted voiding failure. CONCLUSIONS Detrusor ultrastructural analysis is highly predictive of voiding outcome following transurethral prostatectomy in patients with detrusor failure. Patients with ultrastructural features previously described as part of the myohypertrophy pattern do not have a primary diagnosis of bladder outlet obstruction but rather detrusor failure secondary to bladder outlet obstruction.

Outlet obstruction after sling surgery

Whats known on the subject? and What does the study add?

Clinical Outcome in Male Patients With Detrusor Overactivity With Impaired Contractility

Purpose To review the clinical outcomes of patients with voiding dysfunction who have detrusor overactivity with impaired contractility (DOIC) diagnosed with urodynamic studies. Methods Urodynamic reports from 2005 to 2009 were reviewed, and 54 male patients had findings consistent with DOIC. Patients with acontractile or neuropathic bladders were excluded. Clinical outcomes were obtained from patient records. Results Of 54 men, 8 presented with voiding symptoms, 17 had storage symptoms, and 29 had mixed symptoms. Twenty-two had a previous transurethral resection of the prostate. The median follow-up was 12 months. Four patients received no intervention. Two patients were taught intermittent self-catheterization. Five patients underwent surgery to reduce outlet resistance and all reported improvement. Forty-three patients were started on pharmacotherapy; symptomatic improvement was reported by 9 of 16 patients commenced on anticholinergics alone, 6 of 16 on alpha-blockers alone, and 4 of 5 treated with a combination of alpha-blockers and anticholinergics. Eleven patients experienced no difference on pharmacotherapy and 2 reported deterioration. One patient developed acute urinary retention (18 months after commencing treatment with alpha-blockers). No patient had urosepsis. Conclusions Anticholinergics and alpha-blockers appear to be safe in patients with DOIC. The risk of urinary retention and sepsis is low. The majority of patients report symptomatic benefit from either drugs or surgical treatment.

Practical uroflowmetry: PRACTICAL UROFLOWMETRY

Uroflowmetry is an essential investigation that can assist in the diagnosis of common lower urinary tract dysfunctions. This article describes key aspects on performing and interpreting the test.