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Biomedical subjects

C R Woodhouse

Publications and source records attributed to C R Woodhouse.

At least 19 recordsLinked to original sources
PubMed2001

Prospects for fertility in patients born with genitourinary anomalies.

PURPOSE: The effect of congenital genitourinary anomalies on fertility and the impact of current therapies are reviewed. MATERIALS AND METHODS: The literature of each of the 2 components was used to define the present status and to make proposals for future management. RESULTS: Infertility may be caused by gonadal failure (intersex states), failure of sperm transport (exstrophy) or both (bilateral undescended testes). In some conditions it is uncertain whether there are any fertility problems despite an identifiable genital problem. In cases of unilateral undescended testis the fertility rate may be unaffected by surgery and be no different from that in the normal population. Techniques of in vitro fertilization, particularly intracytoplasmic sperm injection, have allowed previously untreatable patients to become parents. Successful pregnancies in patients who had the prune belly syndrome and Klinefelter's syndrome have been reported in the last year. CONCLUSIONS: Prospects for fertility with current techniques and those that might be discovered in the next 20 years should strongly influence decisions about the treatment of infants and children.

Cryptorchidism↗
PubMed2001

Neoplasia in adult exstrophy patients.

OBJECTIVE: To document the incidence of neoplasia in a cohort of 103 patients born with classical exstrophy. PATIENTS AND METHODS: The notes of patients born before 1964 with exstrophy were reviewed retrospectively. The patients were divided into two groups; 42 were thought to be at high risk of developing neoplasia because they had (at some time) had mixing of urine and faeces in a colorectal reservoir, whereas 61 had never been exposed to such a mixture and were thought to have a low risk of neoplasia. RESULTS: At a minimum of 35 years of follow-up, complete data were available for 61 patients; 42 were lost to follow-up, of whom 14 were at high risk and 28 at low risk of neoplasia. In the high-risk group, there were three with colonic carcinoma (two of whom presented before 1980 and died), one with carcinoma in situ of the colon, 10 with benign colonic neoplasms and three with bladder cancer (two of whom died). In the low-risk group, there was one patient with bladder cancer (who died) and one with a clear cell carcinoma of the kidney. Three of the four patients with bladder cancer had undergone cystectomy before 5 years of age. Assuming that all the lost patients are alive and free of neoplasia, the risk of neoplasia in adults born with exstrophy is 17.5%. The main risk is in those who have been exposed to mixing of urine and faeces in a colorectal reservoir (38%). Even in low-risk patients the risk of malignant neoplasia is 3.3% at a median (range) age of 42 (40-44) years, which is 27 times higher than that of the age-matched general population. CONCLUSIONS: Annual colonoscopy of patients deemed at high risk of colorectal neoplasia appears to be an effective screen for colorectal carcinoma, by identifying a premalignant stage, as there were no deaths after this was introduced. Despite bladder closure or diversion surgery within the first few years of life, patients with exstrophy have an almost 700-fold greater incidence of carcinoma of the bladder than the age-matched general population. Early cystectomy is not protective.

Adult↗
PubMed2001

False-positive pregnancy tests in patients with enterocystoplasties.

OBJECTIVE: To determine the incidence and causes of false-positive pregnancy tests in patients with enterocystoplasties. Patients and methods In a pilot study, 15 consecutive patients (both sexes, with any type of urinary diversion) provided a urine sample for testing using the Clearview pregnancy test (Unipath Ltd, Bedford, England). False-positive results occurred only in patients with continent reservoirs; patients with ileal conduits produced no false-positive results and were excluded from the main study. The main study included 23 patients with a urinary reservoir constructed partly or solely of large bowel or ileum, who provided urine and blood samples for the assay of beta human chorionic gonadotrophin and protein. Each urine sample was also analysed with the Clearview test. RESULTS: In the pilot study, three men and two women had positive pregnancy test results. In the main study, 14 patients had a positive Clearview test (nine women and five men). One women was found to be pregnant and was therefore excluded from further analysis, giving a false-positive rate of 57%. There was no difference in the type of reservoir, urine biochemistry and urine analysis results between the positive and negative groups. Frozen/thawed samples all tested negatively. Conclusion It is possible that the mucus produced in enterocystoplasties may be interfering with the pregnancy test. Patients should be aware of this and not rely on commercial test kits. There is some potential that this test system could be adapted for measuring mucus production in urinary diversions.

Adolescent↗
PubMed2001

Management and aetiology of stones in intestinal urinary reservoirs in adolescents.

OBJECTIVE: To review the aetiology and management of reservoir stones in patients with intestinal urinary reservoirs. SUBJECTS AND METHODS: Since 1983 patients with enterocystoplasty have been followed prospectively by protocol. The data sets and notes of 148 patients reconstructed for congenital anomalies were reviewed to retrieve information on the incidence, management and aetiology of reservoir stones. RESULTS: Data were complete on 146 patients, 2 others having been lost to follow-up. Mean follow-up was 3.4 (range 1-14) years. Twenty-three patients formed stones (15.8%). Mean time to stone formation was 45 months (range 1 month to 10 years). In 13 patients the stones were removed by a percutaneous approach. In 9 patients with large stones (>5 cm) an open removal was performed. One patient had a small stone removed through a Kock nipple. All stones were struvite on analysis. All patients with an augmented bladder drained by a supra-pubic Mitrofanoff formed stones at some time. The incidence of stones in other groups was: Kock pouch 50%; reservoirs drained by urethral catheterisation 9%; all other abdominal reservoirs 7.5%. No patient who voided spontaneously formed stones. CONCLUSION: Reservoir stones are infective in composition. The incidence is strongly related to the lack of downward, gravitational emptying. Stones up to 5 cm can be removed percutaneously.

Adolescent↗
PubMed2001

The fate of the abnormal bladder in adolescence.

PURPOSE: The management and reconstruction of the abnormal bladder have made great strides in the last 20 years. Long-term experience comprises patients born more than 20 years ago whose treatment may have been less satisfactory than that available today. The effects of puberty and adolescence on the abnormal bladder and its management in childhood are reviewed. MATERIALS AND METHODS: The current literature on long-term followup is reviewed, and adolescent urology clinic database from 1981 to 1999 is analyzed. RESULTS: In patients with bladder symptoms but no demonstrable abnormality, such as monosymptomatic enuresis, there is usually improvement with time. In the neuropathic bladder function and opportunities for surgery deteriorate especially after puberty. It is essential that proper management be established in childhood. The bladder of a boy with posterior urethral valves also deteriorates with time but in an unpredictable manner (60% develop high pressure and 40% become hypotonic). Constant followup must be done even in patients who are symptomless. The long-term fate of the exstrophy bladder is particularly hard to determine because techniques of reconstruction have changed so dramatically in the last 20 years. In the short term it would seem that urodynamic abnormalities are seen in about 25% of patients, even in those who are continent. Those who have a working bladder at age 10 years have only a 23% chance of having the same by age 20 years. In patients with renal failure due to lower tract dysfunction the bladder must have low pressure and completely empty (with clean intermittent catheterization if necessary) before a transplant can be considered. CONCLUSIONS: The bladder that is abnormal in childhood undergoes changes at puberty that alter storage and voiding function. When the original abnormality is minor, the change may lead to functional improvement. In the severe anomalies changes are almost invariably for the worse and may precipitate renal failure. Children with significant bladder dysfunction will seldom grow out of it.

Adolescent↗
PubMed2000

The effect of intestinal urinary reservoirs on renal function: a 10-year follow-up.

OBJECTIVE: To study the effect of the storage of urine in intestinal reservoirs on long-term renal function and the possible causes of deterioration. PATIENTS AND METHODS: Eighty-seven patients (aged 4-35 years) with bladder exstrophy who underwent reconstruction of the lower urinary tract using a bowel segment were enrolled in a prospective protocol. The glomerular filtration rate (GFR) was measured before and after surgery at 1, 2, 5 and 10 years using 51Cr-ethylenediamine tetra-acetic acid. Patients with a decline in GFR of > 5% were investigated to identify the cause. RESULTS: Of 58 patients with a follow-up of > or = 10 years, 53 were evaluable, four having been lost to follow-up and one refusing to accept the protocol. In these 53 patients, the mean (SD) GFR decreased from 97. 9 (20.4) to 92.9 (23.6) mL/min/1.73 m2 (P = 0.24). However, this decrease was accounted for by 10 patients (19%) whose GFR fell by > or = 20% over the 10 years. The causes of renal deterioration in these 10 patients were; chronic retention and/or infection caused by inadequate catheterization in poorly compliant patients (five), uretero-ileal stenosis (one), a high-pressure reservoir (one) and uncertain causes (three). CONCLUSIONS: For 80% of the patients, the storage of urine in intestinal reservoirs did not change renal function for at least 10 years. However, approximately 20% of patients had some deterioration in renal function during the 10-year follow-up, usually from identifiable and remediable causes. The storage of urine in bowel does not appear to be inherently damaging to kidney function. Patients with an enterocystoplasty need regular monitoring of renal function; when deterioration is detected the urinary tract must be functionally assessed.

Adolescent↗
PubMed1999

What is new in urinary diversion.

There have been some suggestions for changes in technique and investigations of the quality of life. As experience has grown, there have been increasing numbers of reports of complications. Careful attention to technique, especially in nerve-sparing cystectomy and orthotopic cystoplasty may reduce the rate of incontinence. Increasing awareness of quality of life issues should improve preoperative counselling of patients, especially those whose underlying condition is not life-threatening.

Humans↗
PubMed1998

The transverse ileal tube as second-line modification of the Mitrofanoff principle.

With the advantages of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high mobility of the tube), minimized risk of stone formation (no use of staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice for the Mitrofanoff conduit. A longer period of follow-up is needed to determine whether it deserves a permanent place in the reconstructive surgeons' repertoire.

Adolescent↗
PubMed1998

Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube.

PURPOSE: Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique. MATERIALS AND METHODS: From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube. RESULTS: Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization. CONCLUSIONS: With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.

Adolescent↗
PubMed1998

Modified ureterosigmoidostomy (Mainz II)--technique and early results.

OBJECTIVE: To assess the surgical method and results at 3 months of ureterosigmoidostomy modified by reconfiguration of the rectum to make a low-pressure reservoir. PATIENTS AND METHODS: Over the last 8 years, patients undergoing lower urinary tract reconstruction have been followed using a written protocol; the data from patients undergoing a modified ureterosigmoidostomy were retrieved for a retrospective analysis. Two groups of patients were defined: in group A, 15 patients underwent cystectomy and diversion by modified ureterosigmoidostomy and in group B, four patients already had a conventional ureterosigmoidostomy which was incontinent, and the rectum was reconfigured to improve control. The incidence of complications and causes of incontinence were assessed. RESULTS: The rectum was reconfigured by longitudinal incision and transverse closure in a 'U' fashion (Mainz II) in 17 patients, and augmented with ileum in two. There were no surgical complications. In group A all patients were continent at 3 months and in group B only two of four were continent; one patient in group A subsequently became incontinent. All incontinence was caused by chronic retention and overflow. There were no cases of pyelonephritis during follow-up to 29 months and no ureteric reflux was detected. CONCLUSIONS: Modified ureterosigmoidostomy is a safe method of urinary diversion after cystectomy. A longer follow-up is needed to judge its place compared with other forms of diversion. It has a limited place in the management of incontinence in those with a longstanding conventional ureterosigmoidostomy.

Aged↗
PubMed1998

Renal transplantation following renal failure due to urological disorders.

BACKGROUND: Renal allograft outcome, during an 8 year period (1985-1992), has been assessed in 56 renal transplants performed in 55 patients who had end-stage renal failure as a consequence of urological abnormalities. The abnormalities were: primary vesicoureteric reflux (VUR) or renal dysplasia (26 patients); posterior urethral valves (PUV) (15); neuropathic bladders (6); vesico-ureteric tuberculosis (5); bladder exstrophy (3); and prune belly syndrome (1). Six patients had augmented bladders, and eight transplants were performed in seven patients with urinary diversions. RESULTS: Overall, 1 and 5 year actuarial graft survival was 89 and 66%, with mean creatinine of 154 micromol/l +/- 11 (SE) and 145 +/- 9 respectively. Patients with abnormal bladders or conduits (n = 28) had worse graft function than those with normal bladders (n = 28) although graft survival was not significantly different in the two groups at 1 and 5 years: 93 and 75% with normal bladders vs 86 and 57% with abnormal systems. Symptomatic urinary tract infections were common in the first 3 months after transplantation (63%); fever and systemic symptoms occurred in 39% with normal bladders and 59% with abnormal bladders. Urinary tract infection directly contributed to graft loss in six patients with abnormal bladders, but had no consequences in those with normal bladders. CONCLUSIONS: Abnormal bladders must be assessed urodynamically before transplantation, and after transplantation adequacy of urinary drainage must be re-assessed frequently. Prophylactic antibiotics are now given for the first 6 months and urinary tract infections must be treated promptly. With these measures, good results, similar to those of patients without urological problems, can be obtained.

Adolescent↗