Biomedical subjects
Publications and source records attributed to J S Wheeler.
Clear cell adenocarcinoma in a urethral diverticulum in the female is a very rare and unusual tumor. We recently treated two patients with this tumor. Their presentation, histologic evaluation, and management are reviewed in light of the limited experience in the literature.
The modified fluid bridge (flow) test (MFBT) is a simple procedure for detecting bladder neck incompetency using a fluid-filled catheter. The Stresscath (Hollister) female diagnostic catheter is an improved version of the MFBT. We evaluated the ability of the Stresscath to detect bladder neck incompetence in the first 66 female patients referred for urodynamics. The absence or presence of stress incontinence was based on the results from history and physical examinations. The results from the Stresscath correlated with the history showed that the Stresscath had a sensitivity of 0.73 and a specificity of 0.88 in determining stress incontinence due to bladder neck incompetency. The results from the Stresscath correlated with the physical examination (Marshall test) showed that the Stresscath had a sensitivity of 0.86 and a specificity of 0.87 in determining stress incontinence due to bladder neck incompetence. The Stresscath was at least as accurate as the urethral pressure profile in the diagnosis of stress incontinence, at less capital cost.
Detrusor hyperreflexia causing voiding dysfunction in spinal cord injury patients is a difficult problem and is not always treated effectively by anticholinergic agents. We have been investigating electrical stimulation methods to inhibit hyperreflexia and dorsal penile nerve stimulation is the most promising. Six chronic suprasacral spinal cord injury men (average age 36 years) underwent stimulation testing with water cystometry before, during and after stimulation. Dorsal penile stimulation was done with carbon rubber butterfly electrodes (Medtronic) with parameters of 5 pulses per second, 0.35 msec. pulse duration, and current at a level above the threshold for pelvic twitching activity and adjusted for optimal bladder effect (range 25 to 70 mamp.). In all 6 patients the cystometrogram during stimulation showed an increase in bladder volume over the prestimulation cystometrogram (range 27 to 150%). In 2 patients there was no detrusor activity after filling to 500 cc. Stimulation was then stopped and a spontaneous contraction occurred. The cystometrogram conducted after the stimulus also had less volume than that performed during stimulation but it was larger than the prestimulation volume. Penile nerve stimulation was painless with no side effects. Penile nerve electrical stimulation is effective for inhibiting bladder hyperreflexia and should be easily adaptable for chronic home use as an alternative to current therapy.
Neuroprosthetic techniques have been used to facilitate voiding via electrical stimulation for bladder management following spinal cord injury (SCI), but high urethral resistance has been a problem. This problem was investigated here in the chronic, spinal, male cat (C6-T1) using direct bladder and sacral nerve stimulation. Direct bladder stimulation was only conducted during terminal procedures with an open abdomen and with four hook electrodes inserted into the bladder wall. Sacral stimulation was conducted daily during the 10 weeks post-SCI and during terminal procedures. Stimulation was conducted with both implanted epidural electrode and surface electrodes over the sacral bone. Both of these sacral methods stimulated anterior and posterior roots. However, these sacral methods were generally ineffective for inducing voiding during the study. In three of the five animals investigated, stimulation did not empty the bladder. In the remaining two animals, the bladder was emptied with sacral stimulation, but only after return of bladder reflex activity, 2 to 4 weeks post-injury. When poor voiding occurred in spite of high bladder pressures, it indicates high urethral resistance. This was confirmed using video cystourethrography where the membranous urethra was observed to remain closed following stimulation. Direct bladder stimulation was then compared to sacral nerve stimulation during terminal procedures. Direct bladder stimulation induced voiding at a high rate both during and after stimulation, whereas sacral nerve stimulation with implanted electrodes induced voiding at a lower rate and only after stimulation. A simple urethral resistance measure, the ratio of bladder pressure to voiding rate, was lower with direct bladder stimulation than sacral nerve stimulation. Stimulation-facilitated voiding has also been associated with the development of bladder wall hypertrophy. This problem was investigated by evaluating bladder wall thickness postmortem in three groups of animals: the first group was the spinal-stimulated animals detailed above; the additional two groups were a spinal-nonstimulated but instrumented group maintained for 10 weeks following injury, and an intact group of animals. The stimulated spinal cats tended to have the thickest bladder wall followed by the nonstimulated spinal cats. The wall thickness of intact animals served as a control.
We report on a sixty-five-year-old man with hematuria secondary to superficial bladder cancer. Because of previous urethral trauma, a complete transurethral resection of his bladder tumor could not be done. He, therefore, underwent cystectomy, at which time we incidentally found a transitional cell carcinoma of the left ureteral stump that had been left from a previous left nephrectomy for a World War II-related injury. This case underscores the importance of a thorough investigation of the complete urinary tract in a patient with hematuria or other urinary tract symptoms even if an obvious cause is found for his symptoms.
A total of 8 cases of bladder cancer in spinal cord injury men (4 quadriplegics and 4 paraplegics) was seen at 3 medical centers since 1985. All 8 men had a hyperreflexic bladder and 3 of them had associated detrusor-sphincter dyssynergia. Upper tract changes were noted in 4 patients: 2 with distal ureterectasis and 2 with mild hydronephrosis. Only 1 of these men did not have historical films with which to compare results. Histology was transitional cell carcinoma in 6 men and squamous cell carcinoma in 2. Four patients presented with muscle invasion and 1 presented with diffuse carcinoma in situ involving the penile urethra. Three patients presented with superficial transitional cell carcinoma and 2 of them had progression to muscle invasion within 6 and 11 months. All but 2 of the patients with invasive disease underwent a radical operation and urinary diversion. Although followup is short (range 6 to 17 months), 5 patients are well with no evidence of disease and of the 3 who died 2 had no evidence of disease. We found a lower incidence of bladder cancer and a decreased percentage of squamous cell carcinoma than in previous reports, which may reflect an improvement in the lower tract management of these patients. Survival with appropriate bladder cancer treatment appears to correlate well with that of the ambulatory population.
Rectal involvement from prostate cancer occurs in 1.5-11% of cases. A rarer presentation is that of a separate metastasis to the high rectosigmoid colon causing an annular stricture. We present our experience with six such cases who presented with gastrointestinal symptoms. Two of the cases had undergone intestinal resections. All 6 patients had radiographic evidence of an annular stricture in the rectosigmoid area. Retrospective review revealed evidence of metastatic disease in all cases in the form of abnormalities in one or more of the following: intravenous urography, radionuclide bone scan, liver spleen scan, acid phosphatase, or alkaline phosphatase. The mean survival was 9.3 months. This rare presentation of prostate cancer may be difficult to distinguish from primary colorectal cancer and therefore needs to be ruled out to avoid intestinal resections.
The urodynamic results in 68 females with urinary retention were reviewed. There were two groups: 39 patients with neurologic causes for retention, and 29 patients in whom possible causes for retention included: psychological history (15 patients), gynecologic pathology, and urinary tract infection. Nine patients in the neurogenic group and 13 patients in the non-neurogenic group had undergone urethral dilatation with no improvement. Upper urinary tract evaluation was unremarkable. Detrusor failure was the prominent bladder pattern in both groups. In the neurogenic group, low pressure detrusor activity was also present in 10 patients, 3 of whom had sphincter dyssynergia. Flow rate, surface electromyography, and bethanechol supersensitivity test could not help differentiate neurogenic from non-neurogenic detrusor failure. The notation of abnormal bladder sensation did significantly differ between the groups, but was of limited accuracy as an indicator of neurogenic retention. Self-intermittent catheterization was the most effective treatment for both groups, with some patients voiding adequately in follow-up. Although no one test can accurately differentiate neurogenic from nonneurogenic female urinary retention, careful neurourologic evaluation will help guide us to more appropriate management.
To determine the incidence of renal abnormalities among infants exposed to cocaine in utero, we performed ultrasound studies of the genitourinary tract in 100 consecutive infants admitted to the full-term nursery whose mothers had a history of cocaine use during pregnancy and/or a maternal toxicology screen was positive for cocaine. Mean gestational age of the newborns was 38.4 +/- 2.1 weeks. Mean birth weight was 2,846 +/- 561 gm.; 26% of the patients were less than 2,500 gm. and 18% were small for gestational age. Symptoms of drug withdrawal were present in 47 patients. Two newborns had murmurs consistent with a ventricular septal defect. On ultrasonography, 1 newborn had a unilateral multicystic/dysplastic kidney and 1 had kidneys that were 2 standard deviations below normal in size. Based on our results routine renal ultrasound studies do not appear to be indicated in full-term newborns exposed in utero to cocaine.
One hundred patients, 35 with spinal cord injury (SCI) and 65 who were ambulatory, underwent percutaneous nephrolithotomy (PNL). Success of complete stone excision, operative morbidity and mortality were compared in the two patient populations. Stone size and complexity were evaluated by X-ray and a single-stage PNL was done using general anesthesia, bi-planar C-arm fluoroscopy, Amplatz renofascial dilators, and two guide wires. Eleven percent of the patients had previously-placed percutaneous nephrostomy tubes for hydronephrosis and/or pyonephrosis. In the ambulatory group, 98.5% (64/65) were stone-free after the procedure as compared to 85.7% (31/35) in the SCI group. The success rate in those patients who followed postoperative instructions exceeded 96% in both groups of patients. One operative mortality, related to infectious complications, occurred in the SCI group. Major morbidity in the SCI population consisted of three perirenal abscesses, a hydrothorax, an aspiration pneumonia, a respiratory arrest and a nephro-colonic fistula for a rate of 20% (7/35), or 7% of all patients. One major complication, a nephroduodenal fistula, occurred in the ambulatory population. Four patients, three of whom were SCI, required open surgery related to infectious complications. Other significant complications consisted of hemorrhage requiring transfusion, and fever (101.5 degrees F). Minor complications included dislodged nephrostomy tubes, retained stones, and ureteral edema causing obstruction. These complications were three times more common in the SCI population. Percutaneous nephrolithotomy is an effective surgical means for stone removal for SCI and ambulatory patients. The SCI patient has a high incidence of infectious complications causing increased morbidity and mortality.
Electrical stimulation of the bladder wall or sacral nerves may be effective for bladder management in the spinal cord injured patient. However, extensive surgery has been required for electrode implantation. We compared urodynamic responses using surface and minimally invasive epidural stimulating techniques in the chronic spinal male dog. Various surface stimulating techniques were effective: 1) sacral monopolar electrical stimulation with negative electrodes over S2 sacral foramina and positive electrodes on the legs, 2) sacral bipolar electrical stimulation with electrodes only over sacral foramina, 3) perineal monopolar electrical stimulation, and 4) perineal tactile stimulation. Urodynamic responses were similar to those for sacral epidural electrodes implanted adjacent to sacral nerves. Voiding was obtained both during stimulation and poststimulation. Stimulating parameters that were effective for daily voiding with sacral surface electrodes were 10 pps, 30 to 45 ma, 0.6 ms pulse duration, and 2 to 5 sec stimulation train duration.
Urethral activity was investigated in the awake chronic spinal-injured canine using urodynamic recordings, video cystofluoroscopy, and urethral pressure recordings without anesthesia. Bladder contractions and voiding were induced by electrical stimulation with epidural electrodes inserted into the sacral canal. Urethral pressure remained elevated during stimulation and for 1-3 s afterward. Poststimulation voiding occurred with three different patterns: 1) pulsatile voiding in which squirting of urine was associated with contractions in the membranous urethra; 2) "on and off" voiding in which pulsatile flow was interrupted for brief periods of time; and 3) steady-stream voiding in which nonpulsatile flow was followed by pulsatile flow. Viewing these voiding patterns with fluoroscopy indicated that the proximal membranous urethra was important in all of the patterns. We conclude that in the chronic spinal-injured canine the skeletal muscle within the membranous urethra (rhabdosphincter) is involved in responses to sacral stimulation and various voiding patterns.
Recent reports have shown that electrical stimulation of the bladder wall or sacral nerves is effective for bladder management in the spinal cord injured (SCI) patient. However, less invasive methods are needed for electrode implantation. A modified percutaneous procedure for implanting needle electrodes in the sacral canal was evaluated. Stimulation with these electrodes were effective for inducing voiding with little residual volume after the recovery of bladder reflexes, 3 weeks after experimental spinal cord injury in the dog. An optimum electrode arrangement involved a single midline monopolar electrode located between sacral foramina L7 and S1. However, at low stimulating current, lateral electrodes adjacent to sacral nerves were more effective than midline electrodes for inducing voiding. Stimulation parameters that were effective for daily voiding were 10 pps, 1.5-5 mA, 0.3 ms pulse duration, and 2- to 3-second stimulation periods.
Ureteroscopic injuries can be treated with endourologic techniques avoiding the morbidity of open operation. We report two cases of ureteral injury following ureteroscopy: one with extravasation, and the other, diagnosed one month postoperatively, with fistula and retroperitoneal urinoma. Both cases were successfully treated by percutaneous approaches. Possible etiology, preventive measures, and treatments are discussed.
Percutaneous nephrolithotomy is still the treatment of choice for selected cases of "surgical" stone disease. This is a case report of the surgical treatment for a renal calculus located in the inferior moiety of right-to-left inferior crossed renal ectopia. After a failed attempt at extracorporeal shock-wave lithotripsy, a successful percutaneous nephrolithotomy was done without complication.
A positive bethanechol supersensitivity test (BST) usually indicates neuropathic detrusor areflexia and warrants neurologic correlation. Seven females, average age thirty-three years, with straining to void and high residual urines, had detrusor areflexia, with a borderline or positive BST, ranging from 19 cm water to 55 cm H2O change in intravesical pressure after 5 mg of subcutaneous bethanechol. However, all patients had a normal neurologic workup, even though 2 patients had insignificant spina bifida occulta. Two of the patients also had prior pelvic surgery, 1 of whom was azotemic, and 4 of the patients had psychosocial problems; factors reported to be associated with a false positive BST. The positive BST is not diagnostic of neurogenic detrusor areflexia because of the many variables that can influence the test. Therefore, the bethanechol supersensitivity test should be interrupted in light of the complete neurourologic evaluation.
Idiopathic anejaculation is a rare cause of infertility usually treated by psychotherapy. However, electrovibration may be a simple, noninvasive adjunct to the treatment of this disorder. In our two cases, we obtained ejaculate adequate for insemination in one patient and noted some gain in orgasmic sensation in the other. The success in these two infertile patients who had already undergone lengthy psychotherapy is promising. Nevertheless, psychotherapy will continue to be the standard of therapy until we have more experience with penile electrovibration.
Smooth muscle tumors of the female urethra are uncommon lesions. Only a few cases of leiomyoma of the female urethra have been reported in the literature. We describe 2 additional cases, review the literature on this rare neoplasm and discuss its management.