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Biomedical subjects

T P Stephenson

Publications and source records attributed to T P Stephenson.

At least 19 recordsLinked to original sources
PubMed1992

The effect of intravesical Marcain instillation on hyperreflexic detrusor contractions.

Thirty-six patients with suprasacral spinal injury were treated with intravesical local anaesthetic instillation. Eighteen of 32 patients (56%) were converted from an 'ice water positive' hyperreflexic state to an 'ice water negative' state by bupivacaine hydrochloride. Four patients treated with lignocaine hydrochloride showed no benefit. Intravesical local anaesthetic instillation is suggested as a possible treatment for selected cases of detrusor hyperreflexia in patients on intermittent catheterisation.

Administration, Intravesical↗
PubMed1992

Complications of clam enterocystoplasty with particular reference to urinary tract infection.

A study was carried out on 112 patients who had undergone a clam procedure. Follow-up extended from 15 months to 8 years. The efficacy of the operation in achieving and maintaining continence in patients with instability and hyper-reflexia was confirmed (93% in the neuropathic group, 91% in the congenital instability group and 78% in the idiopathic group). Complications were common and included inability to void (requiring self-catheterisation), haematuria, mucus production and recurrent urinary tract infection. Complete bacteriological data were obtained on 80 patients; 30% were infected pre-operatively (all but 4 in the neuropathic group) but 66% had bacteriuria at the time of assessment after surgery. Subjectively, 17 patients (24%) who "never" got infected had bacteriuria, as did 29 (63%) of those who were "occasionally" infected. Objectively, 84% of patients on intermittent self-catheterisation (ISC) had positive cultures, but even in those voiding spontaneously bacteriuria was present in 60%. Careful follow-up of these patients is mandatory and a more rigorous approach to eradication of infection and subsequent prophylaxis has been instituted.

Adolescent↗
PubMed1992

Techniques and complications of substitution and augmentation cystoplasties.

Techniques of achieving a docile lower urinary tract and continence mechanisms using bowel segments have improved unmeasurably over the last decade. The medium term complications are well documented. The long term problems of chronic infection are being addressed but it remains to be seen whether tumour formation occurs eventually in some patients and whether renal function is better preserved by a continent reconstruction rather than a surface diversion.

Bacteriuria↗
PubMed1992

Lower urinary reconstruction in patients with severely impaired renal function.

With the current techniques available for reconstruction no patient should be transplanted into a surface diversion. Although rigorous follow-up of patients with vesicourethral dysfunction should prevent renal failure occurring, such patients continue to appear. Both groups require reconstruction before transplantation preferably before end stage renal failure is reached since healing is better and the problems of the dry bladder reconstruction avoided. The results from this multidisciplinary group have been rewarding.

Colon↗
PubMed1991

Night studies for primary diurnal and nocturnal enuresis and preliminary results of the "clam" ileocystoplasty.

Modified conventional urodynamic apparatus was used to provide overnight monitoring of bladder and rectal pressure. A group of 26 patients with primary diurnal and nocturnal enuresis underwent both daytime rapid fill cystometry and overnight natural fill cystometry. The overnight study was effective in detecting detrusor instability in 10 patients deemed normal on rapid fill cystometry; 6 of these have now undergone clam ileocystoplasty and 5 are dry; 3 are awaiting this procedure. The clam remains very effective in the management of patients with resistant nocturnal and diurnal enuresis if careful selection is adopted. Overnight cystometry has proved to be an invaluable adjunct to the investigation of patients with primary diurnal and nocturnal enuresis previously felt to be urodynamically normal.

Adolescent↗
PubMed1991

Artificial urinary sphincters around intestinal segments--are they safe?

Artificial urinary sphincters (AUS) were implanted around intestinal segments to achieve urinary continence in 8 patients and faecal continence in 1. In 6 patients the cuff was placed around the lower end of the cystoplasty following bladder neck (5) or urethral (1) erosion. Four are completely dry, 1 on self-intermittent catheterisation (SIC). One has mild stress incontinence. In 1 patient the cuff eroded at 8 months. Two patients had cuffs implanted parastomally to create continent diversion. One is satisfactory on SIC and the other had her AUS explanted because of life-threatening metabolic acidosis. The rectal cuff was explanted because of faecal impaction above the cuff. As an absolute last resort, placing an AUS round a cystoplasty appears little more hazardous than round bladder neck. The use of the AUS for continent diversion has not been pursued because of reliable techniques of non-prosthetic continent diversion. The current model of the AUS is unsuitable for the treatment of faecal incontinence.

Adolescent↗
PubMed1991

Ambulatory urodynamics.

Long-term ambulatory urodynamic monitoring has been employed in 20 patients in an attempt to detect detrusor abnormality not appreciated by conventional cystometry. In 9 female patients with the "urge syndrome" it detected 2 previously unrecognised cases of detrusor instability; in 4 enuretic patients, only 1 of whom was known to be unstable previously, unstable contractions were confirmed, and 2 of 7 cystoplasty patients had high amplitude contractions detected only on ambulatory assessment. The technique provides a more sensitive index of lower urinary tract function than conventional cystometry in such patients.

Adolescent↗
PubMed1991

Permanent urethral stents for detrusor sphincter dyssynergia.

A series of 22 patients, most of whom had spinal injuries with detrusor sphincter dyssynergia, have had Medinvent Wallstents placed across the distal mechanism. All but 8 patients had undergone outflow surgery and 11 had had repeated unsuccessful sphincterotomies. The proximal end of the stent was placed over the verumontanum unless fertility was contemplated, when it was placed immediately below the verumontanum. Fifteen patients achieved complete voiding after placement of the first stent; 3 developed bladder neck obstruction after stenting, but in 1 of these cases resolution occurred after bladder neck incision. The 3 patients with artificial urinary sphincters failed to improve after stenting. Use of the urethral stent for patients with detrusor sphincter dyssynergia and failed sphincterotomy is a major advance. It should probably be the primary treatment in selected cases. Its effect on fertility is currently under assessment.

Humans↗
PubMed1991

Assessment of the long-term results of subtrigonal phenolisation.

Long-term follow-up was conducted on 97 patients who had undergone subtrigonal phenolisation for detrusor instability, bladder hypersensitivity, detrusor hyper-reflexia or interstitial cystitis. The procedure failed to alleviate lower urinary tract dysfunction in 57% of patients; it had an unsustained benefit in 24% and long-term success was experienced by only 19%. It was most effective in the hypersensitive bladder of unknown cause. The incidence of complications (17%) suggests that the procedure should only be undertaken if more invasive measures are the only available alternative, and the possibility of these complications should be explained to the patient.

Administration, Intravesical↗
PubMed1990

Assessment of the poorly contractile or acontractile bladder in the older male in the absence of neuropathy.

Up to 30% of patients who undergo prostatectomy are left with residual symptoms. Most have persistent detrusor instability, but some have poorly contractile or acontractile bladders. Over a 2-year period, 42 neurologically normal patients were shown to have a hypocontractile or acontractile bladder on urodynamic testing; 27 had undergone outflow tract surgery. Four patients who were totally incontinent had undergone at least 2 transurethral resections. The remainder had severe frequency, urgency and nocturia. Urodynamically, all but 7 patients with poor compliance had normal filling cystometrograms, all but 8 had residual urine volumes less than 100 ml, and 26 had less than 5 ml. Thus their symptoms are difficult to explain. Apart from the insertion of an artificial sphincter in those with total incontinence, treatment did not improve any of these patients.

Adult↗
PubMed1990

The "clam": indications and complications.

We have reviewed 78 patients who underwent "clam" enterocystoplasty as part or all of their lower urinary tract reconstruction. Nearly half (32) were non-neuropathic; the remainder were either overtly neuropathic (mainly spina bifida) or suspected neuropathic (mainly the older primary enuretics). Only 5 were non-walkers--all neuropathic. Most patients were operated on for incontinence but 12 had upper tract damage related either to urinary diversion or to poor bladder compliance in the early phase of filling; 69 patients became dry, voiding spontaneously (30), by activation of an artificial urinary sphincter (17) or by self intermittent catheterisation (22). Four patients still have nocturnal enuresis, 3 diurnal enuresis and 2 have stress incontinence. One patient has had a continent diversion. The "clam" procedure has revolutionised bladder reconstruction. Careful review has failed to predict the small number who do not achieve a perfect result.

Adolescent↗
PubMed1989

Poor compliance early in filling in the neuropathic bladder.

A total of 30 patients with known neuropathy, mostly spina bifida, developed poor bladder compliance early in filling demonstrated urodynamically; 20 had bilateral hydronephrosis at the time of presentation and 5 also had severely impaired renal function. After appropriate treatment all of those with normal upper tracts or with bilateral hydronephrosis but normal renal function stabilised or improved. However, all 5 with severely impaired renal function progressed to end-stage renal failure. Poor compliance early in filling is an absolute indication for surgical intervention.

Adolescent↗
PubMed1989

Duplex scanning in suspected vasculogenic impotence: a worthwhile exercise?

The value of duplex scanning in the assessment of impotence was evaluated in 146 impotent men. Scanning was by means of a Diasonics DRF 400 and penile artery measurements were taken before and after the intracorporeal injection of papaverine hydrochloride. The penile/brachial index was measured in 82 patients and its predictive value compared with the results of duplex scanning and papaverine-induced erection. On scanning evidence of good arterial inflow but poor erections, indirect evidence of venous leakage was assumed. The results showed that the deep artery responses best characterised the erectile response, with the dorsal artery being less helpful. All 37 patients with full erections following papaverine exhibited bilateral deep artery peak velocities of greater than or equal to 25 cm/s. Of the remaining 109 sub-optimal responders, 17 also has this finding; all had undergone dynamic cavernosography, with 16 exhibiting venous leakage. The penile/brachial index was found to classify 13 patients incorrectly. A critical value of deep artery response to attain erection is postulated, enabling more logical use of cavernosography. The penile/brachial index was shown to be suspect and it was concluded that duplex scanning is a useful, non-invasive method in the assessment of impotence.

Adult↗
PubMed1988

Experience with the Brindley anterior sacral root stimulator.

Brindley anterior sacral root stimulators have been implanted into 22 spinal cord injured patients from the spinal injury units in Cardiff and Sheffield. The group comprised 20 men and 2 women (15 paraplegics and 7 tetraplegics); 16 patients are using the implant, of whom 11 (68%) are continent. Of the remaining 5, 4, who empty completely, are incontinent because of inability to use the implant with sufficient frequency; 6 patients are not using their implant, though 4 are continent. Of 11 patients with detrusor/sphincter dyssynergia, sphincterotomy was necessary in 3 patients before implantation and in a further 3 after implantation. Of 4 patients with abnormal upper tracts prior to implantation, 2 resolved and 2 deteriorated, in the presence of dyssynergia; 1 patient developed hydronephrosis after implantation, having previously had normal upper tracts. Although erectile function with the stimulator was clinically adequate in 6 patients, in no patient has intercourse been achieved because of concurrent lower limb spasm.

Adult↗
PubMed1988

The problems of substitution cystoplasty.

Substitution cystoplasty was performed in 157 patients aged 4 to 71 years; 62% suffered no post-operative complication. The commonest complication was sphincter-weakness incontinence, found in 18%, mainly in patients having a cystoplasty for interstitial cystitis; it was rare for the patient to complain of this incontinence. Ten per cent suffered incontinence due to colonic overactivity and this occurred in patients with neuropathic sphincter-weakness incontinence or an artificial sphincter; all of these patients complained of their incontinence. This was corrected by "patching" in all cases. Voiding difficulties requiring clean intermittent self-catheterisation occurred in 15%. More worrying was the universal finding, when looked for by blood gas analysis, of a metabolic acidosis with respiratory compensation. It was concluded that in the absence of neuropathy, sphincter weakness or an artificial sphincter, an unmodified ileocaecal segment substitution cystoplasty is adequate; in the presence of neuropathy, sphincter weakness or an artificial sphincter, a "pouch" type of substitution cystoplasty should be performed. All patients should have blood gas analyses from time to time as part of their routine post-operative follow-up.

Acidosis↗
PubMed1988

Pedicled preputial patch urethroplasty.

Pedicled preputial patch urethroplasty has been used in 48 patients for the treatment of urethral strictures that have not responded to endoscopic surgery. The procedure is simple to perform and almost universally applicable. It avoids the problems associated with the use of scrotal skin. Its wider use is recommended.

Follow-Up Studies↗
PubMed1987

An assessment of the complications of the Brantley Scott artificial sphincter.

A Brantley Scott artificial sphincter has been inserted into 95 patients since 1981; more than half of the patients had lower urinary tract neuropathy and most of the others post-TUR incontinence. The main problem with the device has been cuff failure (12), which should be resolved by the new "dipped" cuffs. The major surgical complication has been erosion (10), usually associated with infection. Twenty-four patients had variable degrees of incontinence but the artificial sphincter remains the cornerstone of continence control when other methods have failed or are inappropriate.

Female↗