Biomedical subjects
Publications and source records attributed to T Hald.
New treatment modalities are becoming available for benign prostatic hyperplasia. Permanent or temporary stenting of the prostatic urethra, balloon dilatation of the prostate, and hyperthermia and thermotherapy are in the forefront. None of the methods has found a definite place in the spectrum of indications. Prospective trials are needed to ascertain the safety, efficacy, and durability of results.
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The purpose of this study was to evaluate the efficacy of treatment with recombinant interleukin-2 (rIL-2) and lymphokine-activated killer cells in patients with advanced bladder cancer and to study the induced changes in the distribution of leukocyte subsets in blood and tumor. Nine patients with metastatic transitional cell cancer of the bladder were treated with a continuous infusion of rIL-2 combined with lymphocytes stimulated in vitro with rIL-2. None of the patients responded to the therapy despite substantial changes observed in the immunological cells, both in tumor and blood. The rIL-2 infusion induced migration of leukocytes to the tumors, which was related to increased expression of the adhesion molecule VLA-1 on both peripheral blood mononuclear cells and the endothelial cells of small tumor vessels. Only T-cells, predominately expressing IL-2 receptors, and macrophages infiltrated the tumors. Natural killer cells remained few or absent in the tumors, even though the natural killer cells in peripheral blood were activated by the treatment. This study shows that the present technique of rIL-2 and lymphokine-activated killer cell therapy is able to induce substantial changes in the immune system of patients with metastatic bladder cancer. However, this treatment did not induce tumor regression, which may be due to the advanced stage of disease.
A new scoring system is presented for use in patients with uncomplicated benign prostatic hyperplasia. The system is based on the patients' information on the magnitude of twelve symptoms related to bladder and voiding function (symptom score), and three questions related to sexual function. Furthermore the patients are asked to grade the impact of these symptoms on their daily lives (bother score). Multiplication of the two scores related to bladder and voiding function gives the total score. The score related to sexual function is used only for comparing the situation before and after treatment. The new patient weighted total score may assist in creating a solid base for the indication for and evaluation of surgical and non-surgical treatment of uncomplicated benign prostatic hyperplasia.
The expert committees, which met in Paris in June 1991 under the patronage of WHO to establish a consensus concerning BPH, adopted the recommendations summarised in this report. Despite certain criticisms which can be made, these recommendations offer the advantage of simplicity and uniformity, thereby constituting a "universal language". This will facilitate comparison of patients and therapeutic results, both in everyday practice and in the course of clinical trials. These recommendations will be periodically re-evaluated in the light of clinical experience and technological progress.
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In 26 patients with detrusor-sphincter dyssynergia after a spinal cord injury the resting posterior urethra at cystography was found either closed as in normal subjects or open to a varying degree. Highest intravesical pressure measured at cystometry during uninhibited detrusor contraction was statistically significantly related to the degree of dilatation of the resting posterior urethra. An even higher correlation coefficient was found between the dilatation of the resting posterior urethra and an arbitrary score calculated on the basis of highest cystometric pressure and duration of disease since spinal cord injury. The possible importance of this finding in relation to incontinence after urethral sphincterotomy is discussed.
The bulbocavernosus reflex can be elicited either by penile or urethral stimulation. The mean signal transit time after electrostimulation of the dorsal penile nerve to evoked response in the anal sphincter (35 msec) was only half the signal transit time after stimulation in the posterior urethra (60 msec). Thus, the modified bulbocavernosus reflex elicited either by squeezing the glans penis or by pulling a urethral balloon catheter represents two different reflexes with differenct afferent and probably different intraspinal pathways. In the clinic it is therefore important, when testing the bulbocavernosus reflex, to report how it is elicited.
A case of neurosurgical treatment of recurrent urinary incontinence caused by detrusor hyperreflexia is reported. The importance of cystometry in the diagnosis of recurrent urinary incontinence is stressed.
The bladder function was studied in 15 urologically normal females over 40 years of age. They volunteered for this study which consisted of urodynamic studies and lateral micturition cystourethrography. The data are presented in tables. There are only small differences in the urodynamic parameters between this material and a material of women under 40 years of age. It is clearly demonstrated that a gynaecological cystocele tells little or nothing about the bladder function or bladder support. None of the cystometrograms showed uninhibited detrusor contractions. It is underlined to repeat the micturition studies several times in order to obtain a voiding event which the subject recognizes as normal.
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Bladder denervation can provide useful rehabilitation of bladder function when other measures have failed. Idiopathic hyperactivity may respond best to hyperbaric distension or bladder transection. Procedures performed close to the bladder seem, at present, to be more effective than those near the central nervous system. Procedures have little morbidity, apart from transection. On the average a 50 per cent improvement may be expected, but in all cases it is most important to consider the length of follow-up in reported series.
The between-observer variation was evaluated through three independent estimates of preoperative prostatic weight in each of 40 patients. Error in the estimates was of considerable magnitude irrespective of size of prostates. Experienced urologists did not attain a more reliable estimate than unexperienced doctors. Only about 2/3 of estimates were correct within a range of +/- 25 g. However, there was a statistically significant correlation between estimated and actual operative prostatic weight.
Seven patients were treated by the Schlegel-Mobley version of the vesicostomy. Six had neurogenic bladder and one an inoperable carcinoma of the urethra. There were no immediate complications. Urine collection from the stoma functioned satisfactorily, but stenosis of the stoma developed in three patients. The upper urinary tract was improved except in one debilitated patient, who had renal calculi already at the time of operation. Dilatation of the bladder remnant is a problem. Urinary infection was not positively influenced. It is concluded, that the operation is not ideal, but provided the patient is left with a small capacity of the bladder remnant and meticulous stomal care is given, the method can be recommended for limited use in chronically debilitated patients.
Bladder function was studied in 20 healthy elderly male volunteers using cystometry, uroflowmetry and voiding cystourethrography. Two persons were excluded from the study as neurological examination had shown evidence of organic neurological disease, and one person did not complete the study. 53% of the remaining 17 persons had detrusor hyperreflexia. Urinary flow rates were reduced and maximal intravesical pressures elevated in the persons studied, although they claimed to have a normal voiding pattern. No correlation was found between the reduction of urinary flow rate respectively increase in maximal intravesical pressure and the presence of detrusor hyperreflexia. The high incidence of detrusor reflex disturbances thus suggests that incipient infravesical obstruction in old age and possible subclinical impairment of the central nervous control of the micturition reflex are major etiological factors in detrusor hyperreflexia.
In 152 consecutively selected patients with detrusor hyperreflexia (DH) 96 (63 per cent) had neurological disorders. Thirty-two patients did not show any primary neurological or urological cause for DH. This group was chosen to elucidate the evaluation of possible neurological symptoms in relation to the urological symptomatology. Nine had died and one failed to appear to the neurological examination. Twelve (63 per cent) of the 22 examined patients showed signs of lesions in different parts of the central nervous system, particularly cerebrovascular diseases and myeloneuropathy. Six had had neurological symptoms for years. In two the urological symptoms were first to appear. In the group with no neurological complaints the urological symptoms had existed for 2-30 years. No essential difference was found in the degree of voiding disturbance whether or not neurological signs were disclosed. It is concluded that the discovery of DH should be followed by a neurological examination to disclose further signs of lesions in CNS. Likewise, an extended urological examination with demonstration of DH might help in the evaluation of an obscure neurological disease.
Urodynamic investigations were performed in 9 males, suffering from dysfunction of the bladder neck (detrusor bladder neck dyssynergia). The parameters of micturition were compared with the values in normal males and in patients with prostatic obstruction. By introducing a new factor, the maximum opening time, we found a characteristic pattern in dysfunction of the bladder neck, making selection of patients for endoscopic incision of the bladder neck possible. The maximum and mean flow rates increased significantly in 5 patients treated with incision of the bladder neck. The diagnostic value of voiding cystourethrography and urodynamic investigation is discussed.
The terminology of lower urinary tract function will be standardized by the ICS. This report contains the recommendations dealing with urinary incontinence, procedures related to the evaluation of urine storage (cystometry, urethral closure pressure profile) and units of measurement.