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Journal:	Journal of Urology
Authors:	Barbagli G, Palminteri E, Lazzeri M, Guazzoni G and Turini D.	Issue:	2001, 165: 1918-9

Title:

Long-term outcome of urethroplasty after failed urethrotomy versus primary repair.

Abstract:
This paper is a retrospective review of 93 patients, aged 13-78 (mean 39), who underwent surgical repair for bulbar urethral stricture during the period 1975-1998. The strictures were confined to the bulbar urethra only, and in 46 (49%) patients the urethroplasty was performed as a primary repair, whilst in 47 (51%) it was performed after a previously failed urethrotomy. The aetiology of the strictures was: ischaemic in 37, traumatic in 23, unknown in 17, and inflammatory in 16. The authors found a final success rate of 85% for primary urethroplasty, and 87% after previous failed urethrotomy. They concluded that failed urethrotomy did not influence the long-term outcome of urethroplasty. This paper collects together a very heterogeneous group of patients in order to attain statistically significant numbers: the number of previous urethrotomies ranges widely from1-14 (mean 3); the stricture aetiologies differ considerably; 3 different surgical techniques are included; length of follow-up ranged from 24-299 months (mean 63); and the definition of successful outcome is unclear and made at different stages of follow-up. Their conclusion that previous urethrotomy may make surgery more difficult and influence the choice of surgical technique, but does not affect long-term outcome contrasts with the work of other authors such as Ziprin and Mundy. The inconsistencies referred to above greatly weaken the impact of this work and it must be interpreted with caution.

Reviewer: Steve Garnett

Journal:	BJU International
Authors:	Kukreja RA, Desai RM, Sabnis RB, Patel SH and Desai MR.	Issue:	87: 708-709.

Title:

The urethral instillation of depilatory cream for hair removal after scrotal flap urethroplasty.

Abstract:
Midline scrotal skin flaps are often used for substitution urethroplasty when preputial or penile skin flaps are unavailable. The disadvantage of this technique is that the grafts are prone to hair growth which may lead to encrustation, UTI and stone formation. A number of methods have been described to deal with this problem including simple shaving, radiotherapy and laser photocoagulation. Here the authors instilled depilatory cream urethrally. Of 25 patients who underwent scrotal flap urethroplasty, 16 required depilation. Proprietary depilatory cream, containing calcium thioglycollate, was instilled for 10 mins. Mild dysuria was reported initially but there were no other significant side effects. Results showed that the 16 patients required 4 instillations (2 required six and 2 required eight instillations) with no evidence of hair re-growth at 6 months.

Reviewer: David Scholfield

Journal:	Journal of Urology
Authors:	Andrich DE and Mundy AR	Issue:	2001, 165 1131-1134

Title:

Substitution urethroplasty with buccal mucosal-free grafts

Abstract:
Since Humby first used buccal mucosal-free grafts for urethroplasty in 1941, there has been increased interest in the technique, particularly over the last decade. Success rates in the literature range between 87 and 96%. This retrospective study describes the results of buccal mucosal-free grafts in 128 patients, with a minimum two-year follow up. Seventy-seven patients underwent urethroplasty for a bulbar urethral stricture, 41 for a penile urethral stricture, and the remaining 11 for other conditions (hypospadias, epispadias). The patients with bulbar and urethral strictures underwent patch urethroplasty, whereas the others underwent tube grafts. Most of the bulbar strictures were treated by a one-stage urethroplasty and most of the penile strictures by a two-stage procedure. Follow up was by symptom assessment, flow rates and ascending urethrogram. The re-stricture rate was 11% for patch grafts and 45% for tube grafts. One patient developed a urethro-cutaneous fistula, which was closed urethrally, and 9 patients with penile urethral strictures required minor revision after stage 1. Twenty-seven patients complained of post-micturition dribbling, which was troublesome in 3 cases. The authors conclude that patch graft urethroplasty with buccal mucosal-free grafts are at least as successful as using other materials. Advantages of the buccal mucosal graft include ease of harvesting, shorter operating time compared with flaps, resistance to infection and lack of genital scarring. Tube grafts, however, appear to be no better using buccal mucosa than other materials and the authors have abandoned the one stage tube graft. The authors also comment that any type of substitution urethroplasty has a 10-15 year re-stricture rate of 40-50%; therefore the patients will need to be followed for a further 8-10 years to determine if the initial encouraging results are maintained.

Reviewer: Andrea Cannon

Journal:	Journal of Urology
Authors:	Andrich DE and Mundy AR.	Issue:	2001, 165: 1131-1134

Title:

Substitution urethroplasty with buccal mucosal-free grafts

Abstract:
Substitution urethroplasty is employed when end-to-end anastomosis is not possible following excision of a urethral stricture. It involves augmenting or replacing the circumference of the urethra using a patch or tube. Historically, flaps have been used for this purpose as they carry their own blood supply and graft viability is thought to be improved. Interest has recently focused on the use of free buccal mucosal grafts for this purpose. The authors report on the results of 129 cases in which buccal mucosa has been used for 1 or 2-stage substitution urethroplasty. Patients were followed up for a minimum of 2 years (max 5 years). Restricturing occurred in 11% of cases where patch grafts were used and in 45% of tube grafts (similar to results from series in which flaps had been employed). Buccal mucosal grafts, therefore, may not give significantly better long term results. However, they have the advantage of being easy to harvest, quick to apply and leave an excellent cosmetic result. It remains to be seen whether these encouraging early results are maintained in the fullness of time.

Reviewer: David Scholfield

Journal:	BJU International
Authors:	Lemberger RJ and Bishop MC.	Issue:	2001, 87: 269-272

Title:

Neovaginoplasty using rectosigmoid colon on a superior rectal artery pedicle.

Abstract:
The main indications for vaginal reconstruction are gender reassignment and congenital absence. Small bowel, caecum and sigmoid colon have been utilised previously with favourable results. However the bowel segments above may not be ideal in some cases. Here the authors describe a technique employing a short length of rectosigmoid mobilised on superior rectal artery. The results of seven cases are described. No major postoperative complications were reported. Mucus retention, a problem with using right-sided colon, is reduced due to the use of the short segment (<10cm). Introital stenosis was an initial problem in 4 patients necessitating dilation under anaesthetic (2) or minor introital revision (2).

Reviewer: David Scholfield

Journal:	Journal of Urology
Authors:	Elliott DS and Boone TB.	Issue:	2001, 165: 413-415

Title:

Combined stent and artificial urinary sphincter for management of severe recurrent bladder neck contracture and stress incontinence after prostatectomy: A long term evaluation.

Abstract:
The treatment of men with recurrent bladder neck contracture and stress incontinence following radical prostatectomy is difficult. The problem can be treated by transurethral incision or resection followed by artificial sphincter insertion. However recurrent stricturing requiring frequent instrumentation is a contra-indication for AUS insertion. The technique described here involves placing a UroLume stent across the stricture. Once sufficient epithelialisation of the stent has occurred the AUS is sited. In the 9 patients studied, a significant reduction in the use of pads (6.5 before and 0.7 after) was noted. 88% of patients were satisfied with the result with a mean follow up of 17.5 months.

Reviewer: David Scholfield

Journal:	Journal of Urology
Authors:	Lazzeri M, Beneforti P, Spinelli M, Zanollo A, Barbagli G and Turini D	Issue:	2000, 164 (2): 676-679

Title:

Intravesical resiniferatoxin for the treatment of hypersensitive disorder: a randomized placebo-controlled study.

Abstract:
Capsaicin has shown useful effects in patients with a hypersensitive bladder, but unfortunately instillation often produces severe suprapubic burning. Resiniferatoxin (RT) is a potent analogue of capsaicin, which appears to produce much less bladder discomfort. Lazzeri et al. performed a randomised controlled trial of RT compared to saline instillations in 18 patients with hypersensitive bladder. Patients were followed up for 1-3 months. With RT there was a significant reduction in frequency (43% vs 10%), nocturia (56% vs 20%) and pain score (52% vs 15%) at 30 days compared to placebo. Urodynamics showed no change in flows, voiding desire or voiding pressure, and a non-significant increase in bladder capacity. At 3 months these symptomatic improvements were much smaller compared to placebo, and mainly non-significant. There were no important side effects, and no pathological or cystoscopic changes. The response seems fairly shortlived, but may be sufficient to be useful. One wonders if the dose is sufficient, as some studies have used 100 nM rather than 10nM. Four of 9 RT patients noted mild burning during instillation (none with saline), so these patients were not fully blinded. Overall RT shows significant promise as a treatment for this difficult problem. But we need more RCTs and longer follow-up, and more information about cost and dose.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G and Hauri D	Issue:	2000, 164 (3): 692-69

Title:

Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results.

Abstract:
Botulinum-A toxin (BAT) is bound in intramuscular nerve terminals and selectively blocks the release of acetylcholine from the nerve endings. BAT has been used with some success in conditions characterised by smooth muscle contraction (e.g. achalasia), and in parasympathetic disorders (e.g. hyperhidrosis), and has also been tried by direct injection as an alternative treatment for detrusor-sphincter dyssynergia. Schurch et al. studied the use of BAT in detrusor hyperreflexia (DH). Twenty-one spinal cord injury patients with severe DH resistant to therapy and already performing ISC entered a non-randomised prospective study. Treatment was by injection of BAT into the detrusor at 20-30 sites, using a flexible cystoscope and custom-made 6 Fr needle. At 6 weeks, 17 of 19 patients were completely continent, and 7 had been able to completely stop anticholinergics. Urodynamics showed increases in: volume at first contraction (from 215 to 415 ml), capacity (300 to 480 ml), residual (260 to 490 ml), and compliance (33 to 62 ml / cmH2O). Of 11 patients followed up at 16 and 36 weeks, 7 were completely continent and 4 had minor leaks; all UDS parameters were still significantly improved. There were reportedly no side effects and no morbidity. The duration of response of 9+ months seems sufficient to justify the time-consuming technique. Future studies will have to assess safety, long-term efficacy, and cost-effectiveness. Also RCTs against intravesical capsaicin / resiniferatoxin would be interesting. BAT certainly appears to have potential in treating DH.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Venn SN, Greenwell TJ and Mundy AR	Issue:	2000, 164 (3): 702-707

Title:

The long-term outcome of artificial urinary sphincters.

Abstract:
Artificial urinary sphincter (AUS) placement is a well known technique for treatment of incontinence, with a proven track record over 25+ years. However, few reports of long-term results have appeared. Venn et al. present the long-term results of 100 patients implanted with an AUS by a single surgeon (Prof. Mundy) more than 10 years previously. Revisions of AUS were for 3 main reasons: a) early failure (mechanical problems, especially to put in a higher pressure balloon) b) early explantation (for infection or erosion) c) late replacement (sudden failure of a previously effective AUS). Seventy males and 30 females were operated upon, aged 4-88 years, with no post-op mortality. At a median 11- year follow-up 36 of the original devices were in position; 27 required replacement after a median 7 years; and 37 AUS were removed for infection or erosion (12 subsequently successfully replaced, and 9 remained socially continent without replacement). The overall continence rates are quoted as 84-92% for males, and 73% for females. There was a fairly high rate of removal in women (56 %). Women with previous radiotherapy always did badly but ISC and/or concurrent cystoplasty at AUS placement did not appear to increase the risk of loss of AUS by erosion or infection. These data support the view that in appropriate patients the AUS is an excellent long-term option; in women results are variable, but the AUS is still a reasonable option. The authors provocatively suggest that an AUS should be the ‘next step and not the last resort’ if a previous ‘competently performed anti-stress incontinence procedure’ does not cure incontinence.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Lin DW, Santucci RA, Mayo ME, Lange PH and Mitchell ME	Issue:	2000, 164 (2): 356-359

Title:

Urodynamic evaluation and long-term results of the gastric neobladder in men.

Abstract:
Good results have been reported using the gastric neobladder (GNB) in children, with less severe metabolic disturbances, less mucus production, reduction in UTI, no malignancies, and the possibility of anti-refluxing anastomoses. Lin et al. present their experience in the use of the GNB in adult males undergoing reconstruction after malignancy. Only 8 patients were studied, although the follow-up is for a mean 43 months. GNB patients were assessed by urodynamics a mean of 9 months after surgery and by incontinence questionnaire, and compared to a broader group of 24 patients who underwent reconstruction from ileum or ileocaecal segments, by a variety of techniques. GNBs had lower capacity, poorer compliance, higher incontinence rates, and a degree of chronic dysuria. One third of GNBs required revision for severe incontinence, intractable dysuria, and ureterogastric anastomotic stricture (1 patient each). A lot of the problems are related to the thickness of the stomach wall, which is consequently less compliant, and the production of acid by the gastric mucosa. The authors suggest that GNB without myotomy cannot be recommended for routine use. It should be borne in mind that this is a non-randomised study with a larger and rather inhomogeneous control group (presumably studied retrospectively); however, it does appear that the GNB is significantly inferior to ileal or ileocaecal reservoirs in several important respects.

Reviewer: Jon Sullivan

Journal:	BJU International
Authors:	Bakker E and Wyndaele JJ	Issue:	2000, 86 (3): 248-252

Title:

Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction?

Abstract:
Previous studies suggest that the techniques and timing of toilet training (TT) have changed dramatically over the past half century. Bakker et al. studied changes in TT in Belgium by self-administered questionnaire. The questionnaire was reportedly validated, although the description is scanty. Subjects from three different age bands were asked to complete a questionnaire about the TT of each of their children. Only 3% of respondents were men. The age at which TT began, gradually increased over the past 40 years, and continence was similarly achieved later. Forty years ago 71% of children were continent by day and 61% at night before 18 months; this fell to 17% and 8% respectively in children undergoing toilet training most recently. The title implies a link between changing TT habits and lower urinary tract dysfunction (LUTD). Unfortunately absolutely no evidence is presented that LUTD has become more common in recent years, and even if we accept that it has, the article presents no evidence that this is linked to changes in TT. Similarities between successful behavioural treatments for LUTD and toilet training techniques of the past do not constitute evidence of a link. Perhaps the authors’ next step should be to develop a questionnaire to establish whether LUTD has really increased over the same period.

Reviewer: Jon Sullivan

Journal:	BJU International
Authors:	Chartier-Kastler EJ, Thomas L, Bussel B, Chancellor MB, Richard F and Denys P	Issue:	2000, 86 (1): 52-57

Title:

A urethral stent for the treatment of detrusor-striated sphincter dyssynergia.

Abstract:
Detrusor-striated sphincter dyssynergia (DSSD) leads to impaired bladder emptying and increased voiding pressures in patients with neurogenic lower urinary tract dysfunction, resulting in complications such as hydronephrosis, sepsis, and renal insufficiency. Sphincterotomy was developed as the standard treatment, but heavy bleeding and/or re-operation are not uncommon. There have been reports of success with urethral stents for DSSD. The proposed advantages of stenting are: reversibility, minimal invasiveness, reduced hospital stays, no catheter use and no erectile dysfunction (ED). The authors present results of 40 consecutive patients with DSSD treated using the Ultraflex stent. No blood transfusions were required, and all patients achieved spontaneous reflex voiding. One stent was removed for MRSA chronic bacteriuria (not stated whether this was difficult). No stones, fistulae or obstructions were seen during follow-up. Secondary bladder neck incision was required in 7 patients, and 4 required a second stent to be placed for complete sphincter coverage. In 18 patients, residual at 12 months reduced from 245 to 65 ml. Although 40 patients are reported, only 19 were followed up for over 1 year. The assessment of ED before or after stent placement was reportedly difficult, although no explanation is given. There is some confusion between polygons and polyhedra in the description of the shapes of different stents. There is no discussion of cost, e.g. in relation to other urethral stents or alternative treatments. Urethral stenting seems a useful alternative to sphincterotomy - as suggested by the authors, longer follow-up and randomised controlled trials are needed.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Hassouna MM, Siegel SW, Nyeholt AA, Elhilali MM, van Kerrebroeck PE, Das AK, Gajewski JB, Janknegt RA, Rivas DA, Dijkema H, Milam DF, Oleson KA and Schmidt RA	Issue:	2000, 163 (6): 1849-1854

Title:

Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multicenter study on efficacy and safety.

Abstract:
Sacral neuromodulation has had successful results in patients with lower urinary tract dysfunction, particularly neurogenic in origin. This prospective study assesses the use of neuromodulation in non-neurological patients with refractory urgency and frequency symptoms. Fifty-one patients were studied in 12 centres, assessed by urodynamics, SF-36 and voiding diaries. Patients were randomised to a stimulation (n=25) or a control group (n=26). Comparing stimulation and control patients, there was reduced urgency score (-27% versus -4%), and increased voided volume (+92% versus –1%). Urodynamic follow-up showed the bladder volume at peak detrusor pressure and the maximum filling volume were significantly increased in the stimulation group. The adverse events are pooled with previous studies, and include pain at the implant site (15%), new pain (9%), and infection (6%). When reading the text of this paper, it proved difficult to find out whether these patients had detrusor overactivity or not. This information is only found in a footnote to table 3 – apparently almost all patients had detrusor overactivity, although it is still not completely clear. Indeed detrusor overactivity/instability is not mentioned at all in the article. Table 3 also reveals some large differences in baseline characteristics of the stimulation and control groups, for example a fourfold difference in the peak detrusor pressure during cystometry between groups. This is not explained or even mentioned in the discussion. How were the patients randomised? Are there big differences in severity of detrusor overactivity between the treated and control groups? The other baseline characteristics of the two groups are combined into single figures, so further comparison is not possible. One would normally expect these problems to be highlighted and discussed by the authors. The improvements in the stimulation group compared to baseline certainly appear reasonably impressive. However, given the problems with the control group it is difficult to draw a firm conclusion on the efficacy of neuromodulation in patients with urgency and frequency symptoms based on this article.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Lemack GE and Zimmern PE	Issue:	2000, 163 (6): 1823-1828

Title:

Pressure flow analysis may aid in identifying women with outflow obstruction.

Abstract:
Several authors have recently suggested that bladder outlet obstruction (BOO) may be under diagnosed in women. However, deciding how BOO in women should be defined is a major source of debate in urodynamics, as testified by this article. The authors studied 87 women defined as obstructed on the basis of symptoms, and divided into 3 groups according to the putative cause of obstruction. These were compared to 124 women with stress incontinence as controls. Receiver operating characteristics (ROC) curves were used to define cutoff points for defining BOO in women. The cutoffs suggested are 11 ml/s maximum flow and 21 cmH2O for detrusor pressure at maximum flow. Presumably both cutoffs should be met to define obstruction. The obvious problems, as pointed out in the accompanying editorials, are: first, the use of an obstructive group defined by symptoms, when we know that in men ‘obstructive’ symptoms correlate very poorly with obstruction; and second, the use of a control group formed from women with stress incontinence, many of whom probably have abnormally low outlet resistance. The authors are reasonably pragmatic about their conclusions, as they should be, given the problems above. Although this article contributes something further to the debate on defining BOO in women, it perhaps doesn’t add very much to the science.

Reviewer: Jon Sullivan

Journal:	BJU International
Authors:	Merguerian PA, Reddy PP, Barrieras DJ, Wilson GJ, Woodhouse K, Bagli DJ, McLorie GA and Khoury AE	Issue:	2000, 85 (7): 894-898

Title:

Acellular Bladder Matrix Allografts in the regeneration of functional bladders: evaluation of large-segment (>24 cm2) substitution in a porcine model.

Abstract:
Bladder augmentation is of proven value in managing lower urinary tract dysfunction, but the use of bowel for augmentation causes problems related to both secretion and absorption. Bladder acellular matrix allograft (BAMA) is one of several alternatives for augmentation without using bowel. BAMA is intended to act as a biodegradable scaffold, to induce regeneration of native bladder components to recreate a functional reservoir. Merguerian et al. studied the use of BAMA in pigs. Cadaveric pig bladder was treated to remove all cellular components, producing a graft mainly of collagen, which was implanted into 6 pigs. These pigs were then examined at 1, 2 or 4 weeks after implantation. At 1 week there was moderate inflammation and capillary infiltration; at 2 weeks, resolving inflammation and 1-2 cells thickness of urothelium, plus blood vessels and isolated smooth muscle (SM) cells; at 4 weeks there was a multi-layered urothelium, with well-formed vessels throughout, and bundles of SM cells, but 10% shrinkage of graft area. The authors present an interesting general discussion of alternatives to bowel in bladder augmentation, but devote very little space (6 lines) to discussing their own results in the context of other studies. BAMA seems to have some potential in augmentation – it will be interesting to see whether it can be used successfully in humans.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Weld KJ, Graney MJ and Dmochowski RR	Issue:	2000, 163: 1228-1233

Title:

Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients.

Abstract:
This is a companion to the preceding article (Weld KJ and Dmochowski RR J. Urol. 2000, 163: 768-772), reviewing the relationship between bladder management and changes in bladder compliance during follow-up of the same group of patients. Based on the relationship between various complications and different thresholds for poor compliance in their patients, the authors chose a cut off of 12.5 ml/cm H2O to define poor compliance. Patients were assessed by video-urodynamics (VUDS) within 3 years of injury and then again recently. Oral anticholinergics prescribed between the first and second VUDS were not stopped for the second test. The bladder was filled at 50 ml/min in most patients. The management groups were indwelling catheter (150 patients); SV (74); and CISC (92), followed up for a mean 18.5 years. Reflux, upper tract radiographic abnormality, pyelonephritis and upper tract stones were all statistically associated with low compliance. The percentage of patients with normal compliance decreased in all groups with time since SCI, but this was significant only for those with an indwelling catheter. The percentage with normal compliance at follow-up was highest in those using CISC, intermediate with SV, and lowest with an indwelling catheter. The potential criticisms of this paper are generally the same as for the preceding article. In addition, it could be argued that a filling rate of 50 ml/min is a fast rate to use in SCI patients, as bladder compliance is partly dependent on filling rate in these patients. It has not yet been established what filling rate will produce the most meaningful results - in other words, does poor compliance provoked at higher filling rates better identify patients at risk of upper tract disease? On the other hand, a cut-off of 12.5 ml/cm H2O for normal compliance is quite low, but again there is no accepted standard cut-off point. Hopefully more data will be available in future. To summarise both papers, patients should be advised that CISC is probably the best management in terms of the risk of complications and in preserving bladder compliance, although there will always be other factors in the patient’s final choice.

Reviewer: Jon Sullivan

Journal:	BJU International
Authors:	Fishwick JE, Gough DCS and Flynn KJ	Issue:	2000, 85: 496-497

Title:

The Mitrofanoff procedure: does it last?

Abstract:
This article reviews the authors’ long-term results with the Mitrofanoff procedure in children. In 1992, the authors reported on their experience with the technique in their first 10 patients. Of these, 1 had died, and 1 declined interview, leaving 8 patients for an 8-10 year follow-up assessment by structured questionnaire in the present study. Complications related to the Mitrofanoff included occasional UTI (4 patients), stoma stenosis (4 patients, no revisions required), and bladder stones (4 patients, requiring open surgery). Eight out of 9 patients had ‘no regrets about having undergone a Mitrofanoff reconstruction’ and none ‘would have transferred to an incontinent diversion’. The authors conclude that a Mitrofanoff can remain functional for a period of 10 years. The problem with this admittedly brief paper is that the number of patients is so small, and the clinical details (such as the timing of complications) so scanty. The structured questionnaire used was presumably invalidated, and apparently completed by face-to-face interview. The reported results suggest a reasonable long-term outcome from the Mitrofanoff procedure, but it would have been much better to delay reporting the 10-year follow-up until the number of patients would allow something more than a short anecdotal report.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Hull R, Rudy D, Donovan W, Svanborg C, Wieser I, Stewart C and Darouiche R	Issue:	2000, 163: 215-220

Title:

Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients.

Abstract:
The idea of bacterial interference as a form of therapy is based on work demonstrating that untreated asymptomatic bacteriuria prevents symptomatic UTIs in young girls. Leaving bacteriuria untreated to reduce the risk of UTI could be considered passive bacterial interference. The present article investigates the use of active bacterial interference, inoculating catheter-dependent spinal cord injury patients with a non-pathogenic strain of E. coli in an attempt to prevent UTIs. Selected patients were inoculated with E. coli 83972 after completion of a course of antibiotics and change of any indwelling catheter. Up to 3 inoculations were performed until the patient was colonised. Attempts to colonise failed in 2 patients after 3 inoculations; 5 other patients failed after 1 inoculation and declined further inoculations. The mean duration of successful colonisation was 12.3 months. There were no symptomatic UTIs in over 18 patient years of colonisation, compared to a mean 3.1 UTIs per year before colonisation in these patients. Four out of 6 with failed colonisation had symptomatic UTI, and 5 out of 7 who had been free of UTI while colonised developed UTIs within 3 months of losing colonisation. The authors are cautious in their interpretation of the results, given that this is a small, non-randomised study in a mixed group of CISC and indwelling-catheter patients. The results suggest that E. coli 83972 can be used safely and that it may be a useful form of UTI prophylaxis. Obviously a double-blind randomised controlled trial is the next step.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Weld KJ and Dmochowski RR	Issue:	2000, 163: 768-772

Title:

Effect of bladder management on urological complications in spinal cord injured patients.

Abstract:
Modern management of the bladder is widely considered to be the most important advance in the care of the spinal cord injured (SCI) patient. This article reviews the effect of the type of bladder management on the risk of complications over the long term. The records of 316 patients were assessed for complications and for the type of bladder management. Four groups were defined: spontaneous voiding (SV); indwelling urethral catheter (IUC); suprapubic catheter (SPC); and clean intermittent self-catheterisation (CISC). Over a mean 18.5 years of follow-up IUC was associated with the highest complication rates in most categories: epididymitis, pyelonephritis, upper tract or bladder stone, urethral stricture and periurethral abscess. SPC and SV generally had intermediate levels and CISC the lowest level of complications. For VU reflux and upper tract radiographic abnormalities SPC had the highest level of complications, followed by IUC, SV and then CISC. For the first 10 years of follow-up there was little difference in the level of complications overall, but after this point first IUC and later SPC were clearly associated with higher rates of complications. Obviously there is a great potential for bias in the allocation of bladder management, and the recording or interpretation of complications in this study. Most patients changed bladder management during the study, and were categorised according to predominant management to simplify the analysis, although few patients changed bladder management after the first 3 years. In its favour, this is a very long follow-up of a large group of patients, and it is unlikely that equivalent data from an RCT will ever be available.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Weiss JP and Blaivas JG	Issue:	2000, 163: 5-12

Title:

Nocturia

Abstract:
Nocturia is a common and troublesome symptom that is generally considered as part of the spectrum of LUTS, rather than in its own right. This review is a short but very useful summary of current knowledge. The authors emphasise several important points. Nocturia has hitherto been poorly classified and is still not well understood. Multiple factors are responsible for nocturia, many of which are not primarily problems of the urinary tract. Nocturia causes fatigue and sleep deprivation, increases the risk of night-time falls and is associated with higher levels of sick leave. In assessing nocturia, the authors consider the frequency / volume essential. They set out a classification system for nocturia: nocturnal polyuria, low nocturnal bladder capacity and mixed nocturia. The authors define several indices to use in assessing nocturia. While these would obviously be useful in quantifying and classifying nocturia precisely for research, are they any better than simple inspection of the FV chart in clinical practice? The treatment of nocturia is discussed according to the diagnostic classes above. The importance of nocturnal polyuria is emphasised. The authors consider that the initial treatment should be directed at the treatment of nocturnal polyuria, unless it is a small (or absent) component of the patient’s problem. This is an important message in support of the routine use of frequency volume charts, as classification of the cause of nocturia is effectively impossible without them.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Rosario DJ, Chapple CR, Tophill PR and Woo HH	Issue:	2000, 163: 215-20

Title:

Urodynamic assessment of the bashful bladder

Abstract:
Anyone aware of what is required of patients during video-urodynamics (VUDS) will not be surprised that occasionally men find it impossible to void at all during the test. This article discusses the possible role of ambulatory UDS in assessing these patients further. Over a 3-year period 40 of 1200 men tested (3.3%) were unable to void during VUDS. In 11 patients, a history of difficulty in voiding in public was noted (they do not say whether the other 29 patients were asked about voiding in public). Using ambulatory UDS, 37 men (92.5%) ultimately provided a pressure flow study. Six patients had bladder outlet obstruction (BOO), 6 showed equivocal obstruction, and 25 were unobstructed. In Bristol, if a patient is unable to void during VUDS, we often abandon the imaging and allow the patient to void in private - it is not clear whether this was tried in the present study. One also wonders whether other available information (e.g. uroflowmetry) might have given enough information in some men to effectively rule out BOO without resorting to ambulatory UDS. The discussion makes it clear how little we know about the bashful bladder. The article begs the question: who has a bashful bladder? A man who has always been unable to void in public toilets? Or a man unable to void when standing in front of strangers in the urodynamic department, and with tubes in the urethra and rectum? However, this article does clearly answer the question that it aims to answer: ambulatory UDS will give good diagnostic information on voiding in most men who cannot void during VUDS.

Reviewer: Jon Sullivan

Journal:	British Journal of Urology
Authors:	Seki N, Akazawa K, Senoh K, Kubo S, Tsunoda T, Kimoto Y and Naito S	Issue:	1999, 84: 679-682

Title:

An analysis of risk factors for upper urinary tract deterioration in patients with myelodysplasia

Abstract:
It is generally accepted that upper urinary tract damage in children with myelodysplasia is related to elevated intravesical pressure. This study analyses urodynamic risk factors for upper tract deterioration (UTD) in such patients. Thirty-nine children were evaluated by IVU, cysto-urethrography, filling cystometry at 10-30 ml/min, urethral pressure profilometry, and sphincter EMG. UTD was defined by the presence of hydronephrosis and/or vesicoureteric reflux (VUR). Potential risk factors analysed included bladder compliance (BC), maximum urethral closure pressure (MUCP), detrusor-sphincter dyssynergia (DSD), and detrusor hyperreflexia (DH). DSD and high MUCP were significant factors for the incidence of VUR. Low compliance and high MUCP were significantly associated with hydronephrosis. On multivariate analysis, DSD and high MUCP predicted the presence of VUR (odds ratios 18.8 and 1.1 respectively), and only MUCP was predictive of hydronephrosis (OR 1.1). The values quoted for the ORs for the analysis of MUCP differ between the text and the tables. Low BC was a significant risk factor for UTD on univariate analysis, but not on multivariate analysis. DH was not related to the risk of UTD on either analysis. It is interesting that low BC, and DH, were not independent risk factors for UTD. Poor compliance is generally considered to be predictive of a high risk of UTD in myelodysplastic patients. The authors did not define low bladder compliance, or a high MUCP. The bladder filling rates could be considered rather high, which may explain why mean compliance was noticeably low in this study. No data are given on the incidence of upper tract infection, renal function etc. Further work on the relationship between bladder pressures and upper tract deterioration is needed. This study confirms that in myelodysplastic children, urodynamics help to identify risk factors for hydronephrosis and VUR, and presumably therefore for other upper tract complications.

Reviewer: Jon Sullivan

Journal:	British Journal of Urology
Authors:	Theodorou C, Konidaris D, Moutzouris G and Becopoulos T	Issue:	1999, 84: 461-463

Title:

The urodynamic profile of prostatodynia

Abstract:
Prostatodynia is a syndrome of unknown aetiology, with symptoms characteristic of chronic prostatitis, but with non-purulent prostatic secretions with negative culture. Forty-three men aged 24-59 with symptoms of prostatitis, but with infection excluded, were studied. Further investigations included PSA, DRE, urinary tract US, cystourethroscopy, neurological evaluation, free flow rate, provocative filling water cystometry, sphincter EMG and pressure flow study (PFS). Maximum flow rate was considered low in 65% of men. Fourteen percent had detrusor instability, 62% had an early first sensation of filling and 67% early first desire to void. Of the 25 patients completing PFS, 64% had obstructed micturition, identified to lie at the bladder neck on fluoroscopy, with a mean maximum flow rate of 10 ml/s, and a mean intravesical pressure at maximum flow of 83 ml/s. No sphincter EMG abnormalities were found. The authors conclude that functional obstruction at the bladder neck and high sensitivity during filling are the main urodynamic features of prostatodynia, and that such patients should undergo detailed urodynamic investigation. The criteria for the diagnosis of prostatodynia in this study - e.g. the number of characteristic symptoms required - are not clearly stated. Would all these patients be considered to have prostatodynia by other clinicians? The discussion of the data is brief, with the findings of PFS presented in a form which is difficult to evaluate. The method used to diagnose obstruction (e.g. which nomogram) is not clearly discussed, and the authors used intravesical pressure to diagnose obstruction, rather than detrusor pressure. This is an interesting article, although there are a few doubts about the methods and the interpretation of the results. The suggestion that a large proportion of prostatodynia patients suffer from functional bladder neck obstruction, with the implication that surgery might be helpful, should obviously be evaluated further.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Iselin CE and Webster GD	Issue:	1999, 162: 347-351

Title:

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects

Abstract:
This is an interesting article on patients with urethral distraction defects requiring posterior urethroplasty. Since the distal sphincter mechanism may be damaged by pelvic trauma, bladder neck (BN) function is important after injury. Thus, an open BN at preoperative cystourethrography and cystoscopy indicates a higher risk of postoperative incontinence. The authors identified 15 patients with an open BN from patients treated over 17 years. Those incontinent after urethroplasty were compared with those remaining continent, to identify possible prognostic factors. Two were considered to have been identified: the length of the prostatic and urethral opening (p=0.03) and the presence of a quadrant scar at the BN on endoscopy (p=0.22). The authors concluded that these two factors should be taken into account in the preoperative assessment to identify those that should have a simultaneous anti-incontinence procedure at the time of urethroplasty. They also demonstrated good rates of continence subsequently, after quadrant scar excision and BN reconstruction. There are two main problems with this paper: 1) It does not really assess the significance of an open BN. This should be done by comparing those with and those without an open BN. Data on the postoperative incontinence rates in the closed BN patients would have been interesting. 2) The paper implies that the length of the BN and prostatic urethral opening is a useful prognostic factor for incontinence risk, but there is no description of how the measurement was made. It is therefore difficult to see how anyone could apply this prognostic factor in practice. This is an interesting paper, providing useful new data. Obviously, an uncommon problem such as this will always be difficult to study. The conclusions drawn are logical, but it would have been a stronger paper with the inclusion of additional data and more detailed descriptions of the methods.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Diamond DA, Bauer SB, Dinlenc C, Hendren WH, Peters CA, Atala A, Kelly M and Retik AB	Issue:	1999, 162: 841-845

Title:

Normal urodynamics in patients with bladder exstrophy: are they achievable?

Abstract:
Diamond et al. set out to provide data on urodynamic function of exstrophy patients before and after bladder neck reconstruction (BNR). The authors highlight the lack of good data on urodynamics in exstrophy patients. Of 30 patients analysed, 14 had urodynamics before BNR, 8 before and after, and 8 after BNR. In order to assess bladder compliance (BC) and capacity (Cap.) the bladder outlet was occluded manually as effectively as possible. Poor BC was defined by an end filling pressure of >20 cm H2O, and uninhibited contractions as pressure rises with an amplitude of >15 cm H2O. The most interesting group, those studied before and after BNR, showed higher incidence of poor BC and unstable bladder contractions after surgery. The percentage of patients with demonstrable voiding contractions at capacity rose after BNR. The authors discuss the difficulty in defining voiding contractions when achieving 'functional' capacity by occluding the BN. Variables such as leakage of urine around the catheter or vesicoureteric reflux will affect measurement of BC. The conclusion drawn is that the majority of exstrophy bladders in newborns have normal filling urodynamics before BNR, and that surgery results in substantial changes in BC and bladder 'stability'. Approximately 25% of patients had normal urodynamics after BNR, offering a more hopeful prospect than suggested by others. It is not clear to what extent such deterioration in bladder function may be inevitable, due to possible underlying abnormalities of the bladder associated with exstrophy. Clearly there are considerable difficulties in studying children with this relatively rare condition, not least the technical difficulties of performing urodynamics in children under any circumstances, and especially when bladder outlet resistance is low. However, this paper is a useful addition to existing knowledge on the behaviour of the lower urinary tract in exstrophy patients.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Chancellor MB, Bennett C, Simoneau AR, Finocchiaro MV, Kline C, Bennett JK, Foote JE, Green BG, Martin SH, Killoran RW, Crewalk JA and Rivas DA	Issue:	1999, 161: 1893-1898

Title:

Sphincteric stent versus external sphincterotomy in spinal cord injured men: prospective randomized multicenter trial

Abstract:
This article presents the results of a randomised multicentre trial of external sphincterotomy against the Urolume sphincteric stent. Fifty-seven men with spinal cord injury (SCI) and proven DSD were randomised to treatment by sphincterotomy (n=26) or stenting (n=31), and followed up at regular intervals with urodynamics, questionnaires and upper tract imaging. There were no significant differences in any outcome variables, except shorter hospital stay in the stent group. In both groups, there were significant improvements in maximum detrusor pressure during voiding throughout follow-up and in residual urine at some follow-up visits, but not in bladder capacity. Only 1 of 111 renal units showed hydronephrosis at follow-up (14 of 111 pre-op), and none showed reflux (11 of 111 pre-op). At 24 months all stents were either completely (95%) or >90% (5%) covered with epithelium, and there were no cases of encrustation. Six stents were removed for various reasons, including migration (3 of 6). Four stent patients were treated for urethral strictures, compared to 1 stricture and 2 restenoses in the sphincterotomy group. Autonomic dysreflexia improved or disappeared in more than half of the patients affected preoperatively. This is a good randomised controlled study suggesting that sphincter stenting is as good as sphincterotomy in the treatment of DSD. Presumably power calculations were carried out during trial design but it might have been helpful if the article had discussed the power of the study to detect differences in outcome. Stenting has the advantage over sphincterotomy in that it is potentially reversible (and in this study required a shorter hospital stay) and it offers a useful alternative in the management of DSD.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Choe JM, Gallo ML and Staskin DR	Issue:	1999, 161: 1541-1544

Title:

A provocative manoeuvre to elicit cystometric instability: measuring instability at maximum infusion

Abstract:
This is a study of different manoeuvres to provoke detrusor instability (DI) in 134 women undergoing investigation of urge or mixed urge and stress incontinence. Patients were filled with CO2 at 100 ml/min in the supine position. Provocative manoeuvres included: rising to seated position, hand washing, coughing and sitting on a commode for 1 minute with an instruction not to void. The most provocative manoeuvres were hand washing (19.7%) and sitting on a commode for 1 minute (68.4%). There are some difficulties in generalising the results. First, many investigators have abandoned CO2 cystometry precisely because it is so provocative. Gas is also unphysiological, and prevents assessment of voiding or incontinence. Second, the incidence of DI on filling cystometry was very low (around 4%) and much lower than we would expect in women investigated for incontinence in our practice. Like many centres, we fill patients in a sitting or standing position because they normally experience their symptoms during the day in these postures, which are known to be much more provocative of DI. The issue of provocation during urodynamics is still up for debate. To what extent is clinically relevant DI underdiagnosed on standard cystometry? What is the significance of the unstable waves found during ambulatory urodynamics in asymptomatic volunteers? How provocative are other aspects of technique, such as filling medium temperature, urethral catheters, drainage of residual urine? Certainly, for those centres that use supine cystometry, sitting on the commode for 1 minute appears to be a powerful provocation of DI, and ought to be included amongst the provocations used in patients complaining of urge incontinence.

Reviewer: Jon Sullivan

Journal:	Lancet
Authors:	Niggebrugge AHP, Trimbos JB, Hermans J, Steup W-H and van de Velde CJH	Issue:	1999, 353: 1563-1567

Title:

Influence of abdominal wound closure technique on complications after surgery: a randomised study

Abstract:
Although not specifically urological, this study is of interest to any urologist performing open abdominal surgery. The authors present the results of a randomised study of two different methods of midline abdominal closure. These were the standard continuous running suture (CRS), and a new continuous double loop closure (CDLC) technique designed by the authors to reduce wound dehiscence and wound pain. This technique had previously been tested in animals. In total, 390 patients undergoing midline wound closure at elective (n=281) or emergency (n=109) abdominal surgery were randomised to either the CRS (n=204) or CDLC (n=186) technique, performed using identical polydioxanone sutures. Randomization was stratified according to wound contamination, but not according to emergency or elective surgery. Slightly higher numbers of emergency operations were randomised to CDLC (23% CRS vs 33% CDLC). The numbers of wound complications were not statistically different between the groups. Severe wound pain after surgery was significantly less common in the CDLC group. Despite this, pulmonary complications (17% vs 5%, P=0.0002) and mortality within 30 days (21% vs 8%, P=0.0004) were higher for CDLC than for CRS. The difference in mortality and morbidity persisted when looking only at elective patients. The authors postulate that the higher complication rate of CDLC arose from lower abdominal compliance and greater intra-abdominal hypertension, which is associated with reduced renal and visceral perfusion and higher rates of renal failure and death. The authors suggest that the ideal abdominal closure should combine strength to prevent wound rupture and elasticity to adapt to increased abdominal pressure. This is a useful reminder of the potentially large impact of closure technique on the outcome of surgery.

Reviewer: Jon Sullivan

Journal:	Journal of Urology
Authors:	Armenakas NA, Duckett Cp and McAninch JW	Issue:	1999, 161: 768-771

Title:

Indications for nonoperative management of renal stab wounds.

Abstract:
The authors evaluate a subgroup of 199 patients with penetrating renal injuries presenting to the San Francisco General Hospital over a 20-year period with the aim of establishing treatment guidelines for the successful management of such injuries. Whenever possible, preoperative staging was performed with IVU or CT. Associated organ injuries occurred in 122 patients (61%) and involved predominantly the liver, pleura, diaphragm and spleen. In 57 patients (28.5%), the severity of the renal associated injuries required immediate exploration, preventing preoperative imaging. Based upon initial clinical and radiological findings, 108 were managed non-operatively with bed rest, three of which later required exploration for delayed renal bleeding. Renal reconstruction in those patients requiring immediate operative intervention (92 renal units) resulted in only 12% of patients requiring nephrectomy.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R and Paiss T	Issue:	1999, 161: 422-428

Title:

Ileal neobladder: complications and functional results in 363 patients after 11 years of follow-up

Abstract:
Hautmann et al. present the complications and functional results of ileal neobladder in 363 patients. Perioperative death occurred in 11 patients (3%), while early neobladder related complications occurred in 56 patients (15.4%) and late complications in 85 patients (23.4%) with an early and late re-operation rate of 0.3 and 4.4% respectively. The re-operation rate for neobladder unrelated early and late complications was 12.1% and 12.4% respectively. A total of 3.9% of patients required intermittent self-catheterisation, while unacceptable day and night time incontinence (defined as more than one pad required per day or night) was 4.1% and 5% respectively.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Manning M, Junemann KP, Scheepe JR, Braun P, Krautschick A and Alken P.	Issue:	1998, 160: 1680-1684

Title:

Long-term follow-up and selection criteria for penile revascularisation in erectile failure.

Abstract:
The authors report the outcome of a variety of microsurgical penile re-vascularisation procedures in a cohort of 62 impotent men who had not responded to pharmacological treatment. Thirty-four percent of patients achieved spontaneous erections more than 30 months after surgery while a further 20% were able to achieve erections with the aid of pharmacological therapies. Overall, success was lower in patients with two of the following: diabetes, nicotine abuse, alcoholism, obesity, hyperlipidaemia, arterial hypertension and coronary heart disease. The authors’ results with the Modified Mannheim triple anastomosis are also discussed. The authors compare their experience with those of others and draw attention to the lack of standardisation of surgical methods as well as definition of the successful outcome of revascularisation surgery.

Reviewer: Andrew Elves

Journal:	British Journal of Urology
Authors:	Kojima Y, Asaka H, Ando Y, Takanashi R and Kohri K.	Issue:	1998, 82: 114-117

Title:

Mucosal morphological changes in the ileal neobladder.

Abstract:
The use of ileum to make neobladders is becoming more frequent. An understanding of the ultrastructural changes that occur following the formation of the neobladder will be important in understanding the metabolic changes that occur in these patients and in devising strategies to prevent them. The mucosal villi in these neobladders become shorter (as do the microvilli), and cell borders become irregular. Fewer senile cells are seen in the tips of the villi.

Reviewer: Jonathan Glass

Journal:	British Journal of Urology
Authors:	Woodhouse CRJ, Christofides M.	Issue:	1998, 81: 247-252.

Title:

Modified ureterosigmoidostomy (MainzII) - technique and early results

Abstract:
Not a comprehensive paper, but it is interesting that one of the major neo-bladder reconstructors in the UK favours ureterosigmoidostomy for patients undergoing a cystectomy for bladder cancer. It is important to remember that 65% of these patients will have died from their disease within 5 years.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Swami KS, Feneley RCL, Hammonds JC, Abrams P.	Issue:	1988, 81: 68-72.

Title:

Detrusor myectomy for detrusor overactivity: a minimum 1 year follow up.

Abstract:
Another potential strategy for the treatment of bladder instability (see above). This paper reviews a novel treatment in two groups of patients - those with bladder instability and those with a neuropathic bladder. The numbers are small and there is no control group but there appears to be improvement in certain urodynamic parameters which is reflected in symptomatic improvement. The technique seems to work better in the idiopathic group.

Reviewer: Mark Feneley

Journal:	Urology
Authors:	Racioppi M, D’Addessi A, Fanasca A, Mingrone G, Benedetti G, Capristo E, Maussier ML, Valenza V, Alcini A, Alcini E.	Issue:	1997, 50 (6): 888-892.

Title:

Vitamin b12 and folic acid plasma levels after ileocaecal and ileal neobladder reconstruction.

Abstract:
The authors set out to compare the long term serum levels of Vit B12 and folic acid in patients that had undergone orthotopic bladder substitution. 34 patients had ileocaecal resection (10cm caecum and 5-6cm of terminal ileum) and 16 had ileal reservoirs (35-40 cm ileum taken 20cm from ileocaecal valve). Mean follow up was 59.8 +/- 41.9 months. All patients had a normal follow up folic acid, haemoglobin and haematocrit. Vit B12 was significantly lower in patients that had an extensive ileal resection, with 18.75% of patients having a Vit B12 level below the bottom of the normal range. It was normal in the group that had undergone Ileocaecal resection. The authors conclude that extensive ileal resection leads to a reduction in Vit B12, however there is no correlation between time after surgery and fall in B12.

Reviewer: Mark Feneley

Journal:	Urology
Authors:	Kalloo NB, Jeffs RD and Gearhart JP	Issue:	1997, 50 (6): 967-971.

Title:

Long-termnutritional consequences of bowel segment use for lower urinary tract reconstruction in paediatric patients

Abstract:
The authors reviewed patients that had undergone lower urinary tract reconstruction with intestine before the age of 18, with a minimum of three years since surgery. They examined 29 patients, on average 45 cm of intestine was used, colon exclusively in 3. Serum B12, MMA (an indicator of B12 deficiency), carotene and folate were measeured. All three patients that had colon used exclusively for reconstruction had normal serum levels for all compunds examined, in the remaining 26 patients 13 had abnormalities, 5 having more than one. B12 was low in 4, MMA high in 7, Folate low in 4 and carotene low in 4. Of the 13 patients with abnormalities none had clinical symptoms. The authors conclude that although no patients were symptomatic from nutritional deficiencies, long term effects may be significant and they recommend nutritional monitoring in patients that undergo reconstruction using intestine. The authors emphasise the importance of dietary folate in women of child bearing age and stress closer vigilance in women following urological reconstruction.

Reviewer: Mark Feneley

Journal:	European Urology
Authors:	Kelly JD, Kernohan RM, Keane PF.	Issue:	1997, 32: 30-33.

Title:

Symptomatic outcome following clam ileocystoplasty.

Abstract:
This study reported the subjective outcome of patients following clam ileocystoplasty based on objectively validated symptom scores. Cystoplasties were performed on 27 patients after failed drug treatment for mostly idiopathic detrusor instability and spina bifida. Mean follow-up was 18 months. The majority (3/4) reported a subjective improvement in symptoms but some said they were worse. All patients noted voiding dysfunction of variable severity. Worst results were obtained in young women having surgery for detrusor instability.

Reviewer: Mark Feneley

Journal:	European Urology
Authors:	Filipas D, Egle UT, Budenbender C, Fisch M, Fichtner J, Hoffman SO, Hohenfellner R.	Issue:	1997, 32: 23-29.

Title:

Quality of life and health in patients with urinary diversion: a comparison of incontinent versus continent urinary diversion.

Abstract:
This retrospective study attempted to identify factors associated with a good quality of life in patients undergoing incontinent and continent urinary diversion. Eighty-one patients with a mean age of 55 years were included. The best quality of life occurred in patients in employment who had a continent reservoir for benign disease. There was no difference between the two groups regarding diversion-related symptoms, global satisfaction with life and sociodemographic data. Worst results were achieved in patients with high levels of depression or anxiety and in those patients with low levels of global satisfaction with life, health and urinary diversion.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Stein R, Fisch M, Beetz R, Matani Y, Doi Y, Hohenfellner K, Burger RA, Abol-Enein H and Hohenfellner R.	Issue:	1997, 79: 354-361.

Title:

Urinary diversion in children and young adults using the Mainz Pouch I technique.

Abstract:
Rudi Hohenfellner's group presents their experience with the Mainz I urinary diversion in 91 children and adolescents over an eleven-year period. The complication rate was low for this type of procedure. The majority of patients had either improvement or stabilisation of upper tract dilatation at last follow-up with 5.5% showing a slight increase in upper tract dilatation. Almost 13% of renal units required reoperation for ureteric stenosis. All patients with an appendiceal stoma were continent. Two of 32 patients with an intussuscepted and invaginated ileal nipple required reoperation due to incontinence. Five patients developed calculi. There were no cases of severe acidosis and no bowel neoplasms, although clearly much longer follow-up is needed to assess the risk of the latter.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Singh G and Thomas DG.	Issue:	1997, 79: 328-332.

Title:

Bowel problems after enterocystoplasty.

Abstract:
The authors assessed changes in bowel habit in 69 patients who had undergone an enterocystoplasty by means of a postal questionnaire. Thirty percent of patients found that their bowel function had not returned to normal after three years follow-up. The main problems were increased frequency, looser faeces and worse incontinence. Non-neuropathic as well as neuropathic patients had bowel disturbances following surgery. The flaw in this study is that the questionnaire relied on the patient recalling symptoms over at least a three-year period and it has been shown that this is unreliable. Clearly, a prospective study of bowel symptoms including quality of life assessment is needed.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Shokeir AA.	Issue:	1997, 79: 324-327.

Title:

Interposition of ileum in the ureter: a clinical study with long-term follow up.

Abstract:
The author presents nine patients (follow up 2-7 years) in whom a long upper ureteric defect was replaced by ileal loop interposition with preservation of lower ureteric continuity and thus avoidance of vesico-ureteric reflux. The proximal anastomosis was end-to-end and an end-to-side anastomosis was performed on the distal ureter which was spatulated. The ileal segment was tailored in three cases. The indications were iatrogenic injuries leading to fistula, stricture or avulsion of the ureter. All of the patients achieved satisfactory drainage with improved or stabilised creatinine clearance. There were no metabolic abnormalities.

Reviewer: Mark Feneley

Journal:	New England Journal of Medicine
Authors:	Pryor JL, Kent First M, Muallem A, van Bergen AH, Nolten WE, Meisner L, Roberts KP.	Issue:	1997, 336: 534-539.

Title:

Microdeletions in the Y chromosome of infertile men.

Abstract:
Some infertile men with oligospermia and azospermia have small deletions in the Y chromosome. In this paper, its incidence is reported to be 7% in 200 consecutive infertile men, 23% in men with azospermia and 2% in fertile men. The size and position of the deletion correlated poorly with the severity of spermatogenic failure.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Carr LK, MacDiarmid SA and Webster GD.	Issue:	1997, 157: 104-108.

Title:

Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty.

Abstract:
Results of 2-stage scrotal in-lay urethroplasty for complex lengthy urethral strictures may be compromised by hair formation, diverticula and a recurrence rate of up to 25% resulting from urine induced dermatitis. The authors present the results of staged urethroplasty using meshed split skin graft from non-hair bearing skin in 15 patients with median follow-up of 38 months. Overall time to closure was 5.5 months, with 6 men requiring revision of the graft before closure. A successful outcome defined by history and retrograde urethrography was achieved in 12 of the 15 men. Among the failures two patients had evidence of stricture recurrence at the proximal anastomosis while 1 patient had recurrent stenosis of the entire neourethra. The authors conclude that the described method offers comparable results to and benefits over scrotal in-lay procedures.

Reviewer: Mark Feneley

Journal:	World Journal of Urology
Authors:	Donovan JF, Hade DK, Lavelle JP, Kwon ED.	Issue:	1996, 14: 370-374.

Title:

Continent small intestine reservoir construction: a tapered intussusceptum promotes sustained continence.

Abstract:
A new continent reservoir is proposed with a continent nipple valve. The procedure has been performed in 21 dogs with absolute continence in all 21. Pressure cystometry in 9 animals shows continence in the reservoirs with pressures up to 40mm of water.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Struder UE, Hansjorg D, Thalman GN, Springer JP and Turner WH.	Issue:	1996, 156:1913-1917.

Title:

Anti-reflux nipples or afferent tubular segments in patients with ileal low pressure bladder substitutes.

Abstract:
The authors compared anti-reflux nipples with afferent tubular segments in 70 patients with ileal low pressure bladder substitutes. There were no differences over the follow-up period of 57 and 45 months between those with an anti-reflux nipple valve and those without an anti-reflux mechanism with regard to functional reservoir capacity, incidence of infection, urinary continence, voiding habits and serum electrolytes, urea and creatinine. Severe upper tract dilation was noted to be more common in those patients with an anti-reflux mechanism. Video urodynamics failed to demonstrate reflux in either group. This study concluded that mechanisms to prevent reflux in patients with orthotopic low pressure substitutes are unjustified and associated with a high complication rate.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Albers P, Fichtner J, Bruhl P, and Muller S C.	Issue:	1996, 156: 1611-1614.

Title:

Long-term results of internal urethrotomy

Abstract:
The authors report a retrospective analysis of long-term results of internal urethrotomy in 937 patients treated at two centres, evaluating risk factors for stricture recurrence. Mean follow-up was 4.6 years at one centre (357 patients) and 3.2 years at the second centre (580 patients). Strictures recurred in 96 of 357 (29.9%) and 260 of 580 (44.8%) patients respectively. Risk factors for recurrence were etiology, stricture longer than 1 cm, and post operative catheter drainage for greater than 3 days. Recurrence was defined by urinary flow rates and clinical symptoms. The authors conclude that urethroplasty should be considered for patients at high risk of recurrence and with more than one treatment failure after urethrotomy.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Thomas PJ, Desouza NM and Mundy AR	Issue:	1996, 78: 681-685.

Title:

The effects of detubularisation and outflow competence in substitution cystoplasty.

Abstract:
The Guy's reconstructive unit report pre- and postoperative urodynamic results of 142 patients undergoing orthotopic substitution cystoplasty, either with a straight or a detubularised bowel segment comprising a few cm of terminal ileum to the proximal 1/3 of the transverse colon. Detubularisation produced a 38% greater capacity than the straight cystoplasty (although the authors felt this was less than predicted by mathematical models) and shifts the urodynamic detrusor pressure curve to the right. The detubularised segments did not exhibit less contractility than straight segments and a similar fraction (8-10%) of patients with each type of cystoplasty leaked urine, often due to sphincter weakness. The authors point out a potential problem with detubularised cystoplasty being limitation of its mobility due to folds of the mesentery which may preclude anastomosis to the urethra.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Thuroff JW, Mattiasson A, Andersen JT, Hedlund H, Hinman F,Hoyhenfelner M.	Issue:	1996, 78: 516-523.

Title:

The standardisation of terminology and assessment of functional characteristics of intestinal urinary reservoirs.

Abstract:
This document has been produced by the International Continence Society to provide a framework for a standardised assessment of the physiology of normal and abnormal intestinal urinary reservoirs. While acknowledging that current understanding is limited, it includes guidance with respect to terminology of surgical procedures, patient assessment, investigations such as enterocysometry and outlet pressure profilometry and a classification of storage dysfunction.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Jarrow JP and DeFranzo AJ	Issue:	1996, 156: 982-985.

Title:

Long-term results of arterial bypass surgery for impotence secondary to segmental vascular disease.

Abstract:
This paper is a retrospective review of arterial bypass surgery in 11 impotent men with non-atheromatous vascular disease. Initial evaluation included history, physical examination and failure to respond adequately to pharmacological therapy. Nine patients underwent dorsal artery bypass and 2 arterialisation of the deep dorsal vein. Mean follow-up was 50 months. Initial duplex ultrasonography demonstrated a significant increase in cavernosal artery peak systolic pressure blood flow velocity and patent anastomosis in all but 1 patient. Success rate (satisfactory vaginal intercourse without supplemental therapy) initially was 82% falling to 64% at long-term follow-up. The authors suggest arterial bypass surgery can be successful in selected patients without generalised atheroma or other risk factors for impotence.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Serrano DP, Flechner SM, Modlin CS, Wyner LM and Novick AC	Issue:	1996, 156: 885-888.

Title:

Transplantation into the long-term defunctionalized bladder.

Abstract:
This paper is a retrospective report in 5 patients undergoing transplantation into a long-term defunctionalised bladder. All patients were evaluated prior to transplantation with cystoscopy, voiding cystography, urodynamics and demonstration of continence. Four patients achieved a satisfactory result with median bladder capacity of 300 ml, peak flow of 18 ml/s and residual volume of 15 ml. One patient required self-catheterisation in order to void. Graft function was good in all patients with follow-up ranging between 64 and 120 months. This paper demonstrates that in carefully selected patients may undergo successful transplantation into a long-term defunctionalised bladder.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Benoit G, Blanchet P, Eschwege P, Alexandre L, Bensadoun H and Charpentier B.	Issue:	1996, 156: 881-884.

Title:

Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomised study.

Abstract:
This paper evaluates the advantages and disadvantages of ureteral stents in renal transplant recipients in the setting of a prospective randomised control study. One hundred and ninety four renal transplant patients were randomised to have stent insertion (97 patients) or no stent insertion (97 patients). In the stented group, urinary leakage was observed in 1 patient and urinary tract infection in 35 patients. In the non-stented group, 6 patients had urinary leaks, 4 had obstruction and 32 had urinary tract infections. At one year, patient and graft survival, and renal function was similar between the two groups. Stent encrustation was not observed in any of the stented group. The authors conclude use of ureteral stents decreases the incidence of urinary leakage and obstruction in renal transplantation surgery.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Hauri D.	Issue:	1996, 156: 931-935.

Title:

Can gastric pouch as orthotopic bladder replacement be used in adults?

Abstract:
This paper reports the use of stomach to provide an orthotopic bladder replacement in 19 men with non-metastatic grade 3 bladder cancer. 14 patients are continent (not defined) night and day, five patients are continent by day with partial incontinence at night. There was no correlation between continence and pouch capacity. Stone formation does not appear to be a significant long-term problem. No leakage of the anastomosis between pouch and urethra was noted, stenosis of the ureter at the site of implantation was observed in 2 patients and corrected by open operation. Two patients developed the dysuria or haematuria syndrome associated with a perforating ulcer requiring operative intervention. Both these patients had a urinary pH less than 4 with marked hypergastrinaemia. This mode of orthotopic bladder replacement would appear feasible although problems associated with urinary acidity may necessitate a proton pump inhibitor.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Kolettis PN, Klein EA, Novick AC, Winters JC and Appell RA.	Issue:	1996, 156: 926-930.

Title:

The Le Bag orthotopic urinary diversion.

Abstract:
This paper reviews the authors experience with the Le Bag orthotopic urinary diversion for treatment of bladder cancer in 38 cases with mean follow-up of 14 months. There was no difference in major complication rates between the hand sewn and stapled pouches (25 and 18% respectively). Mild hyperchloraemic acidosis was observed in most patients and appeared to be related to pouch length. Six patients developed upper tract problems including 3 cases of ureteral obstruction and 1 of recurrent tumour in the distal ureter. All cases of reflux (7/33) were in patients with non-tunnelled anastomoses. Day time continence rate was 91%, and 80% of the patients are completely dry or have only mild nocturnal incontinence. The authors conclude that this technique is a technically feasible form of urinary diversion simplified by the use of absorbable staples without increasing the complication rate and with functional results similar to other forms of orthotopic diversion.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Christmas TJ, Holmes SAV and Hendry WF.	Issue:	1996, 78: 69-73.

Title:

Bladder replacement by ileocystoplasty: the final treatment for interstitial cystitis.

Abstract:
This paper discusses possible aetiological factors and several management options for patients with interstitial cystitis (IC), including urinary diversion with its inherent psychological, sexual and social drawbacks. Twenty seven patients (23 women; 4 men) with IC refractory to conservative therapies underwent cystectomy and orthotopic substitution using 60 cm of ileum (Kock pouch). Six of these patients had trigone preservation and suffered recurrent symptoms. The remaining 21 patients who underwent total cystectomy were all relieved of pain (median follow-up 30 months).

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Mundy AR	Issue:	1996, 78: 243-247.

Title:

Urethroplasty for posterior urethral strictures.

Abstract:
Professor Mundy retrospectively compares his results of 82 transperineal bulboprostatic anastomotic urethroplasties (AU) with 59 patch (penile or scrotal skin-flap) urethroplasties (PU). The strictures for which this surgery was performed were either <2 cm in the bulbar urethra or any length in the membranous urethra as long as the remaining urethra was normal. In terms of re-stricturing at 5, 10 and 15 years, AU patients fared considerably better. Factors associated with re-stricture were age >55 years and pre-operative impotence. Mundy suggests these risk factors could have impaired urethral blood flow in common. 7% patients undergoing AU became permanently impotent post-operatively. He concluded that AU is the best repair technique for such strictures, with the exception of those due to blast injury or associated with an abnormal remaining urethra.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Hendry WF	Issue:	1996, 78: 74-79.

Title:

Bladder replacement by ileocystoplasty after cystectomy for cancer: comparison of two techniques.

Abstract:
Mr Hendry describes two techniques of ileocystoplasty he has used to orthotopically reconstruct twenty patients undergoing radical cystoprostatectomy or subtotal cystectomy for in situ or invasive (pT1-4) bladder cancer. Ten hemi-Kock pouches with ureteric implantation into an unopened afferent ileal segment featuring an inverted nipple valve and ten W-pouches with ureters implanted directly via serosal tunnels were performed - diagrams helpfully illustrate the procedures. Operating time averaged 4-5 hours and 3-4 hours respectively. Follow-up ranges from three to 48 months and the only serious upper tract complication was hydronephrosis and hydroureter causing acute renal failure due to eversion of a nipple valve. Mr Hendry concludes that the direct implantation method requires less time and less ileum.

Reviewer: Mark Feneley