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ABSTRACT: What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.
BJU International 11/2011; 109(9):1280-93. · 2.84 Impact Factor
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ABSTRACT: What's known on the subject? and What does the study add? This is a review of urethral diverticula in females. In addition to modes of presentation, differential diagnosis, complications and surgical management, the increasingly recognised value of computerised axial imaging, especially with MRI, is highlighted. Urethral diverticula are rare but under-diagnosed entities that may cause a variety of urinary and pelvic symptoms in women. They are best demonstrated by magnetic resonance imaging and micturating cysto-urethrography prior to transvaginal surgical excision. Although unlikely, the possibility of malignant transformation should not be forgotten.
BJU International 11/2011; 108 Suppl 2:20-3. · 2.84 Impact Factor
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ABSTRACT: Urological practice includes several chronic conditions, which greatly impact patients’ lifestyles. For those patients who
are disappointed by conventional medical treatments, or for those who just wishto optimize or contribute to their own healthcare,
numerous alternative therapies are available. Many are ineffective, some are promising, but as yet, very few have sufficient
clinical evidence to justify widespread adoption. Evidence-based medicine will help discriminate between therapies, so appropriately
and carefully designed trials of each treatment should be welcomed by all practitioners. A variety of alternative medical
therapies are discussed in this chapter, primarily concentrating on their use in benign and malignant conditions of the prostate.
01/2010: pages 221-232;
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ABSTRACT: OBJECTIVE To review the outcomes of consecutive patients referred with urethral diverticula to a tertiary centre; to investigate the diagnostic, imaging and surgical factors relevant to success. PATIENTS AND METHODS A retrospective case note review of 30 consecutive patients treated between January 1999-2007 was performed and data retrieved on demographics, presenting symptoms, preoperative imaging, surgical technique, outcomes and need for further intervention. RESULTS All patients were tertiary referrals, four after failed local repairs. The mean (range) interval between initial presentation and repair was 48 (1-264) months. Only seven patients (23%) had all three symptoms of the classical triad of dysuria, dyspareunia and dribble, whilst 23% did not have any of these symptoms. Transvaginal ultrasonography showed the diverticulum in six of nine patients, voiding cysto-urethrography (VCUG) in 13 of 18 patients (72%) and magnetic resonance imaging (MRI) in all 11 patients assessed. MRI accurately imaged diverticular configuration, whilst VCUG assessed detrusor and sphincteric function. Twenty-nine (97%) patients were cured of their diverticulum; all 19 patients with simple diverticula were cured at first attempt, whilst 17 procedures were performed on the 11 patients with complex diverticula. Twenty of 24 (83%) repairs were successful using three-layered closure, 9 of 11 using Martius interposition, and one using bulbospongiosus muscle interposition. There were three primary repair failures; two circumferential diverticula repaired with Martius interposition and one partial horseshoe diverticulum repaired without interposition had partial recurrences. Both were subsequently repaired successfully. One patient with chronic urethral pain from multiple, infected recurrences was eventually diverted. A pubovaginal sling procedure was required in only one (3.3%) patient with persistent pre-existing stress urinary incontinence (SUI). CONCLUSIONS The presentation of urethral diverticula is diverse and diagnosis frequently delayed. The most useful preoperative imaging is MRI and VCUG to assess diverticular anatomy and detrusor/urethral function, respectively. In simple cases, transvaginal excision with three-layer closure is curative, whilst more extensive, persistent or SUI-associated diverticula require Martius fat interposition. Sling procedures can be deferred until the results of primary excision are assessed.
BJU International 03/2009; 103(11):1550-4. · 2.84 Impact Factor
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ABSTRACT: To evaluate screening cystoscopy as the long-term follow up in patients with an enterocystoplasty for > or =10 years.
We performed a prospective analysis of 92 consecutive patients who attended our endoscopy suite for regular check cystoscopy as per standard follow-up. This is performed for all patients with cystoplasty performed at our institute after 10 years. The data were recorded on patient demographics, original diagnosis and type of cystoplasty. In all, 53 of these patients consented to undergo bladder biopsies at the same time.
The median (range) follow-up was 15 (10-33) years. No cancer was identified with either surveillance cystoscopy or on routine biopsies. Chronic inflammation was identified in 25 biopsies (27%). Villous atrophy was present in 12 (55%) ileal patch and three (12.5%) colonic patch biopsies. During this study, the first and only case of malignancy in a cystoplasty at our institution was diagnosed in a symptomatic patient. She had intermittent haematuria and recurrent urinary tract infections (UTIs). She previously had a normal surveillance cystoscopy.
We feel that it is not necessary to perform yearly check cystoscopies in patients with augmented bladders at least in the first 15 years, as cancer has not yet been detected with surveillance cystoscopy in this patient group. However, if the patient develops haematuria or other worrisome symptoms including suprapubic pain and recurrent unexplained UTIs a full evaluation, including cystoscopy and computerized tomography should be undertaken.
BJU International 03/2009; 104(3):392-5. · 2.84 Impact Factor
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ABSTRACT: To review the outcomes of all patients referred with vesico-vaginal (V VF) and urethro-vaginal (UVF) fistulae to a tertiary centre, and to investigate the patient, fistula and surgical factors relevant to success.
We reviewed retrospectively the case-notes of 41 consecutive patients (32 with V VF; nine with UVF) treated between January 2000 and January 2006.
All patients were tertiary referrals, eight after failed local repairs. Four patients were unsalvageable and had a supravesical diversion. In all there were 47 repairs (23 transvaginal; 24 transabdominal) on 37 patients by two specialist surgeons. The fistula was closed in 92%; five V VF and one UVF required a second procedure, and one V VF a third procedure. One patient with a V VF awaits a second attempt at repair. In one V VF (one attempt) and one UVF (three attempts) the procedure failed and the patient had a diversion. A transvaginal approach cured all 11 patients with a V VF and eight of nine with a UVF, whilst an abdominal approach used for larger/complex fistulae was successful in 18 of 24 (75%) attempts (P = 0.13). The major determinants of success were fistula size (>3 cm; P = 0.02) and the availability of tissue for interposition. V VF repairs using Martius/omental interposition were mostly successful, whilst abdominal repairs in which omentum was unavailable tended to fail (37.5% cure; P = 0.002).
Despite varied aetiology, V VF/UVF were repaired successfully in 92% of patients. Complex (V VF) fistulae were challenging and a quarter of these required more than one attempt. Failure of repair was more likely in larger fistulae (>3 cm) requiring an abdominal approach, if omental interposition was not possible. Good-quality tissue interposition for complex fistula is essential for a successful outcome.
BJU International 01/2009; 103(8):1122-6. · 2.84 Impact Factor
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ABSTRACT: The introduction of the artificial urinary sphincter (AUS) in 1972 was heralded as a revolution for the treatment of genuine stress incontinence. Initial enthusiasm was tempered by disappointment as complications occurred. The device has now been in routine clinical use for more than 30 years, and the indications and surgical principles involved in its use along with short-term and long-term outcomes are more clearly defined. Hence, we reviewed the literature to clarify the role of the AUS and offer a possible solution to its problems in the guise of a new sphincter.
A MEDLINE search was performed and all articles relating to the role of the AUS for the treatment of urinary incontinence were reviewed.
The AMS 800 (American Medical Systems, Minnetonka, Minnesota) provides urinary continence in 73% of cases (range 61% to 96%) and it has a complication rate of 12% (range 3% to 33%) for mechanical failure, 4.5% to 67% for early infection/erosion, 15% for late erosion and 7% for delayed recurrent incontinence. The literature supports the role of the AUS as an important and reliable treatment modality for stress urinary incontinence and intrinsic sphincter deficiency. However, it is not suitable in all patients and its use for the management of hypermobility is controversial. Hence, careful patient selection according to indication is required with full preoperative counseling.
Despite its reliability for achieving urinary continence the AMS 800 is not perfect. Newer devices, such as that being developed at our institution, may offer improved outcomes and decreased complication rates.
The Journal of Urology 09/2005; 174(2):418-24. · 3.75 Impact Factor
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ABSTRACT: To quantify experience of pelvic fracture-related urethral trauma (PFUT), a condition not often encountered and managed by urologists.
The consultant urologists of the UK and Ireland were contacted informally to establish their experience with PFUT and its management, both immediate and delayed. In addition, particular individuals thought to have a specific interest in PFUT were targeted for more data.
The overall response rate was 49% (235 responders), representing 78% of urological departments, including all the targeted individuals. Of the responders, 129 (55%) had never seen PFUT in 1-25 years of consultant practice. Only four urologists (2% of responders) saw three or more cases a year. Another four (2%) saw one or two cases per year and the remaining 98 (41%) saw PFUT less frequently. Acutely, 69% of urologists who treated PFUT did so by placing a urethral catheter. Subsequent strictures were treated endoscopically for as long as this was possible. The other 31% inserted a suprapubic catheter and referred the patient for reconstructive surgery if needed. Those who used urethroplasty for strictures after PFUT were identified and targeted; half used urethral mobilization and spatulated anastomosis alone. Only three surgeons performed more than five procedures a year.
Whatever a specialist reconstructive unit might do, practice in the wider urological community is different. Even within specialized units, PFUT is rare and the surgical management is often significantly different from published 'expert' opinion.
BJU International 08/2005; 96(1):127-30. · 2.84 Impact Factor
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ABSTRACT: To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease.
The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications.
The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%).
The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.
BJU International 11/2004; 94(7):1037-9. · 2.84 Impact Factor
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BJU International 10/2004; 94(5):705-18. · 2.84 Impact Factor
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BJU International 10/2004; 94(5):719-37. · 2.84 Impact Factor
