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A R Mundy

Publications and source records attributed to A R Mundy.

At least 19 recordsLinked to original sources
PubMed2006

Standing the test of time: the long-term results of urethroplasty.

The principle indication for urethral surgery is stricture disease. There are a number of factors that influence the outcome of surgery including location of the stricture, stricture length, aetiology, previous surgery and selection of procedure. Outcomes for different techniques are summarised. The gold standard remains anastomotic urethroplasty, where appropriate, with patch urethroplasty or two-stage stage procedures for more complicated strictures especially the penile urethra.

Anastomosis, Surgical↗
PubMed2006

Management of urethral strictures.

Controlled clinical trials are unusual in surgery, rare in urology, and almost non-existent as far as the management of urethral stricture is concerned. What data there are come largely from so called "expert opinion" and the quality of this is variable. None the less, the number of so called experts, past and present, is comparatively small and in broad principle their views more or less coincide. Although this review is therefore inevitably biased, it is unlikely that expert opinion will take issue with most of the general points raised here.

Anastomosis, Surgical↗
PubMed2006

Three-dimensional MRI of the male urethrae with implanted artificial sphincters: initial results.

The aim of this study was to develop a method for simultaneous 3D visualization of a new type of artificial urethral sphincter (AUS) and adjacent urinary structures. Serial MR tomograms were acquired from seven men after AUS implantation. 3D reconstruction was performed by thresholding original (positive) and inverted (negative) image intensity and by subsequently fusing positive and negative images. Results show that the bladder, cuff and balloons of the AUS of originally high intensity were imaged in 3D by thresholding the positive datasets. The urethrae and corpora cavernosa penis of originally low intensity were displayed in 3D by thresholding the negative datasets. Fusion of the positive and negative datasets allowed simultaneous visualization of the AUS complex and adjacent urinary structures. All the structures of interest were also clearly seen by interactive multiplanar reformatting. Coronal tomographic datasets provided better 3D and reformatted 2D images than sagittal and transverse datasets. This technique offers a simple means for evaluating the complex urethral anatomy and the AUS, and has potential for improved 3D visualization of many other complex morphological and pathological conditions.

Aged↗
PubMed2005

Structural assessment of the urethral sphincter in women with urinary retention.

PURPOSE: The pathophysiology of urinary retention in women is generally unknown but a subgroup of women with urinary retention have been diagnosed as having so-called primary disorder of sphincter relaxation on the basis of an abnormal urethral sphincter electromyogram. It was suggested this sphincter overactivity could lead to work hypertrophy of the urethral rhabdosphincter and in this study we looked for any evidence of such muscle fiber hypertrophy. MATERIALS AND METHODS: In 9 women 18 to 45 years old (mean age 31.6) with urinary retention and overactive urethral sphincter electromyogram, light and electron microscopy were used to examine core needle biopsies of the urethral rhabdosphincter taken under transvaginal ultrasound control. Of the 9 patients only 5 biopsies processed for light microscopy and 4 processed for electron microscopy contained striated urethral muscle fibers. The results of these biopsies were compared to the morphology of a control specimen from a postmenopausal woman without a history of urinary retention. RESULTS: On light microscopy the urethral rhabdosphincter fiber diameter did not differ among patients (mean average 7.6 mum), was less than that reported in the literature (15 to 20), but did not differ from that of the control (mean 9.9). In all patients electron microscopy showed excessive peripheral sarcoplasm with lipid and glycogen deposition, and sarcoplasmic accumulation of normal mitochondria. These ultrastructural abnormalities were not seen in the control. CONCLUSIONS: To our knowledge this is the first morphological description of the urethral rhabdosphincter in a subgroup of women with urinary retention. Mean rhabdosphincter fiber diameter was approximately the same in patients and controls. This study does not support the previous theory that urethral sphincter overactivity in a subgroup of women with urinary retention leads to work hyperplasia of urethral rhabdosphincter fibers. An alternative hypothesis is suggested.

Adolescent↗
PubMed2004

Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective.

PURPOSE: We developed an algorithm for the management of urethral stricture based on cost-effectiveness. MATERIALS AND METHODS: United Kingdom medical and hospital costs associated with the current management of urethral stricture were calculated using private medical insurance schedules of reimbursement and clean intermittent self-catheterization supply costs. These costs were applied to 126 new patients treated endoscopically for urethral stricture in a general urological setting between January 1, 1991 and December 31, 1999. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention following initial intervention. Mean followup available was 25 months (range 1 to 132). RESULTS: The costs were urethrotomy/urethral dilation 2,250.00 pounds sterling (3,375.00 dollars, ratio 1.00), simple 1-stage urethroplasty 5,015.00 pounds sterling (7,522.50 dollars, ratio 2.23), complex 1-stage urethroplasty 5,335.00 pounds sterling (8,002.50 dollars, ratio 2.37) and 2-stage urethroplasty 10,370 pounds sterling (15,555.00 dollars, ratio 4.61). Of the 126 patients assessed 60 (47.6%) required more than 1 endoscopic retreatments (mean 3.13 each), 50 performed biweekly clean intermittent self-catheterization and 7 underwent urethroplasty during followup. The total cost per patient for all 126 patients for stricture treatment during followup was 6,113 pounds sterling (9,170 dollars). This cost was calculated by multiplying procedure cost by the number of procedures performed. A strategy of urethrotomy or urethral dilation as first line treatment, followed by urethroplasty for recurrence yielded a total cost per patient of 5,866 pounds sterling (8,799 dollars). CONCLUSIONS: A strategy of initial urethrotomy or urethral dilation followed by urethroplasty in patients with recurrent stricture proves to be the most cost-effective strategy. This financially based strategy concurs with evidence based best practice for urethral stricture management.

Adolescent↗
PubMed2004

The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain.

PURPOSE: We assess the medium and long-term morbidity of buccal mucosal graft (BMG) harvest for urethroplasty, and evaluate the effect of nonclosure of the graft harvest site on postoperative pain. MATERIALS AND METHODS: A questionnaire was mailed to 110 men who underwent BMG urethroplasty between January 1, 1997 and August 31, 2002. Demographic data and side effects of BMG harvest, including oral pain, sensation and intake, were assessed postoperatively. A prospective study was then performed to compare 20 unselected men whose BMG donor site was closed with a group of 20 men in whom it was left open using a 5-point analog pain score that was completed twice daily for the first 5 postoperative days. RESULTS: A total of 49 men with a median age of 49 years (range 23 to 73) returned questionnaires relating to 57 BMG harvests. Of the graft harvests 47 (83%) were associated with postoperative pain, which was worse than expected in 24 (51%). Of the 57 patients 51 (90%) resumed oral liquid intake within 24 hours and 44 (77%) resumed normal diet within 1 week. Postoperative side effects included perioral numbness in 39 (68%) patients with 15 (26%) having residual numbness after 6 months, initial difficulty with mouth opening in 38 (67%) with 5 (9%) having persistent problems, changes in salivation in 6 (11%) and mucous retention cyst that required excision in 1 (2%). The men in the prospective donor site study had a median age of 51 years (range 24 to 70). Mean pain score for patients with donor site closure was 3.68 and was significantly higher than that for patients without donor site closure (2.26, p < 0.01). CONCLUSIONS: Buccal mucosal graft harvest is not a pain-free procedure. Closure of the harvest donor site appears to worsen this pain and it may be best to leave harvest sites open. The main long-term complications are perioral numbness, persistent difficulty with mouth opening and change in salivary function.

Adult↗
PubMed2003

Electromyographic detection of purinergic activity in Guinea pig detrusor smooth muscle.

PURPOSE: We recorded nerve mediated extracellular electrical activity from guinea pig detrusor smooth muscle strips using suction electrodes and determined the electrophysiological origins of this signal and its relationship to contractile activity. MATERIALS AND METHODS: Mucosa-free detrusor strips were prepared from male guinea pigs sacrificed under Home Office license, physiologically superfused, attached to a pressure transducer and electrically stimulated (0.1 millisecond pulses). Electrical signals recorded using a bipolar reversible suction electrode were processed and recorded simultaneously with changes in strip tension. The effect of superfusion with alpha, beta-methylene adenosine triphosphate (ATP), atropine, extracellular [CaCl(2)] depletion and pharmacological Ca2+ channel blockade on the electrical and mechanical signals was determined. RESULTS: A biphasic electrical signal was consistently recorded from 37 detrusor strips. The signal was sensitive to graded reduction in [CaCl(2)] of the superfusate and abolished by tetrodotoxin in 7 preparations. The signal was also abolished in 12 preparations by alpha, beta-methylene ATP in association with an attenuated contraction but not significantly reduced in amplitude (p = 0.77) despite a significant reduction in tension with atropine (mean plus or minus SD 74% +/- 14% of control, p <0.001). The signal was attenuated to a mean maximum of 9% +/- 3% of control by pharmacological Ca2+ channel blockade and the remaining signal was abolished by alpha, beta-methylene ATP. CONCLUSIONS: The extracellular electrical signal recorded from guinea pig detrusor strips using suction electrodes originates from a purinergic mechanism. Although an atropine sensitive component may be present, the signal does not depend on cholinergic neuromuscular transmission and would not be expected to be generated by normal human detrusor. Provided that the electrophysiological basis of purinergic neurotransmission in guinea pig and human bladders is similar suction electrodes may be a valuable tool with which to evaluate in vitro and clinically by electromyography the pathological purinergic neuromuscular transmission that can be expressed in addition to normal cholinergic mechanisms in detrusor from dysfunctional human bladders.

Adenosine Triphosphate↗
PubMed2003

The fear of prostate cancer in men with lower urinary tract symptoms: should symptomatic men be screened?

OBJECTIVE: To explore the concerns and worries in men with uncomplicated lower urinary tract symptoms (LUTS, but no evidence of prostate cancer) relating to their symptoms. PATIENTS AND METHODS: There is no current prostate cancer screening programme in the UK. Evidence suggests that men with LUTS have the same risk of prostate cancer as aged-matched asymptomatic men. However, most men with LUTS are 'screened' with a digital rectal examination (DRE) and prostate specific antigen (PSA) testing as part of routine assessment. Whether this screening offers any benefit to patients and whether national screening for prostate cancer and subsequent early treatment offer any long-term survival or quality of life benefit is uncertain. Thus 30 men with uncomplicated LUTS were qualitatively interviewed to explore their concerns and worries about their symptoms. Interviews were transcribed verbatim and subjected to content analysis using validated techniques. RESULTS: Of the 30 men, 22 (73%) expressed a fear of prostate cancer at the time of their initial presentation. This fear was independent of race, social class and symptom severity; older men were less worried. Of the 22, 15 (68%) stated that after reassurance their symptoms were less bothersome and easier to cope with. CONCLUSIONS: These findings suggest there is a considerable gain in health by explicitly addressing the concerns of prostate cancer in men with uncomplicated LUTS. Informing these men of their true risk of prostate cancer (before or after a DRE and PSA estimate) may alleviate much of the bother associated with their symptoms. Despite no evidence of any greater risk of prostate cancer than in asymptomatic men, symptomatic men should continue to be screened after appropriate counselling.

Decision Making↗
PubMed2003

Lifestyle and behavioural interventions for men on watchful waiting with uncomplicated lower urinary tract symptoms: a national multidisciplinary survey.

OBJECTIVE: To determine the use of lifestyle and behavioural interventions in the UK for symptom control in men with uncomplicated lower urinary tract symptoms (LUTS) on watchful waiting (WW). METHOD: Semi-structured interviews with urologists, nurse practitioners and continence advisors were used to obtain a list of lifestyle and behavioural interventions used in men with LUTS. From the 18 interventions identified, a survey was constructed asking how often these interventions were used in routine practice. The survey was sent to 100 consultant urologists (British Association of Urological Surgeons), 100 nurse practitioners (British Association of Urological Nurses), and 100 continence advisors (International Continence Society) with an interest in male urology, all randomly selected. RESULTS: Of 248 (83%) responses, 236 were suitable for analysis; 193 (82%) of the respondents reported using lifestyle or behavioural interventions in men on WW with uncomplicated LUTS. The most frequently used interventions were education about the prostate and bladder, avoiding caffeine, urethral milking and reassuring men that they do not have prostate cancer. The use of lifestyle and behavioural interventions showed an 'all-or-none' pattern. Respondents used either few or many of the 18 interventions identified. There was considerable variation in the extent to which these interventions were used among the survey groups (P < 0.01); urologists used these interventions the least and continence advisors the most. CONCLUSIONS: Lifestyle and behavioural interventions are advised by many medical professionals to men on WW with uncomplicated LUTS. However, the use varies considerably, with some medical professionals advising many of these interventions and some a few or none at all. Further research is required to define and test the effectiveness of these interventions in reducing LUTS.

Aged↗
PubMed2003

The problems of penile urethroplasty with particular reference to 2-stage reconstructions.

PURPOSE: We evaluate the anecdotal high revision rate of 2-stage urethroplasty. MATERIALS AND METHODS: The short-term revision rates after 1-stage (139 cases) and 2-stage (103) urethroplasties were compared. RESULTS: There were 4 revisions after 1-stage urethroplasty (4 of 139, 3%) and all involved the penile urethra (20%). The revision rate was 37.8% after stage 1 and 25.3% after stage 2 and of 2-stage urethroplasty 85%, involved the penile urethra. CONCLUSIONS: Although 2-stage has a significantly lower re-stricture rate than 1-stage urethroplasty for complex strictures in the penile urethra, it does so at the expense of a significantly higher revision rate particularly of the penile urethra.

Adolescent↗
PubMed2003

The long-term results of urethroplasty.

PURPOSE: We update our long-term data on the effectiveness of urethroplasty. MATERIALS AND METHODS: A total of 166 patients operated on before 1990 are currently under followup or lived at least 10 years after surgery. Anastomotic urethroplasty was performed in 82 patients and substitution urethroplasty in 84. RESULTS: The 5, 10 and 15-year re-stricture rates after anastomotic urethroplasty were 12%, 13% and 14%, respectively, and the complication rate was 7%. The 5, 10 and 15-year re-stricture rates after substitution urethroplasty were 21%, 31% and 58%, respectively, and the complication rate was 33%. CONCLUSIONS: The results of anastomotic urethroplasty are good and sustained in the long term, while the results of substitution urethroplasty deteriorate steadily with time and there is definite room for improvement. An anastomotic repair should be performed in preference to a substitution repair when possible.

Adolescent↗
PubMed2003

The type of urethroplasty for a pelvic fracture urethral distraction defect cannot be predicted preoperatively.

PURPOSE: Pelvic fracture urethral distraction defects (PFUDDs) are generally treated surgically by a so-called progression approach consisting of 4 steps to achieve a tension-free bulboprostatic anastomosis. Implicitly the need for each step in turn is predictable according to the length of the defect on preoperative x-ray. MATERIALS AND METHODS: In 62 evaluable patients with PFUDD the length of the radiological defect was compared with the surgical steps that subsequently proved necessary to achieve a tension-free bulboprostatic anastomosis. RESULTS: Except at the extremes of length there was no association between defect length and the scale of the surgery performed. CONCLUSIONS: Surgeons preparing to repair an apparently short PFUDD cannot assume that simple repair is all that is necessary.

Fractures, Bone↗
PubMed2002

[Effects of peripheral functional electrostimulation in obstructive bladder instability].

INTRODUCTION: The aim of this study was to assess the effects of peripheral functional electrical stimulation (FES) in patients with detrusor instability (DI) secondary to obstructive Benign Prostatic Hyperplasia (BPH). SUBJECTS, MATERIAL & METHODS: Nine patients with urodynamically proven DI secondary to BPH were investigated. Sensory and pudendo-anal reflex thresholds were determined in each patient to individually optimise FES. A standard fill cystometry was then performed and individually optimised FES was given when an unstable detrusor contraction occurred. Non stimulated contractions were used as controls. The effects of FES were analysed by measuring the mean area under the unstable pressure curves with and without FES and were expressed as percentage suppression. RESULTS: The percentage suppression in the mean area under the curves after stimulation was < 10%. There was no statistically significant difference between controls and FES using a two tailed, paired students t-Test (p > 0.1) at 95% confidence level (p > or = 0.05). CONCLUSION: FES did not significantly suppress unstable bladder contractions in patients with DI secondary to BPH. This finding suggests that obstructive DI does not depend on sacral reflex mechanisms and supports the view that it has a peripheral pathophysiological origin (myogenic and/or nerve endings).

Electric Stimulation Therapy↗
PubMed2002

Testicular torsion unravelled.

Testicular torsion is a true vascular emergency-prompt diagnosis and surgical management is critical. If treatment is not instigated within 4-6 hours of the onset of pain, irreversible testicular infarction may result, necessitating orchidectomy. This review presents the key features, management principles and medicolegal considerations of this serious condition.

Diagnosis, Differential↗
PubMed2002

Outcome of the artificial urinary sphincter in female patients.

PURPOSE: We reviewed the outcome in female patients at our unit in whom an artificial urinary sphincter was inserted. MATERIALS AND METHODS: We reviewed notes on 68 patients and mailed a questionnaire to those without recent followup. RESULTS: Median time since insertion was 12 years. Overall 25 patients (37%) had the original artificial urinary sphincter in situ and were dry at a median followup of 7 years. The artificial urinary sphincter was replaced for loss of function in 12 patients, of whom 11 were dry with the replaced device. The device was removed for erosion or infection in 31 patients, of whom 19 underwent successful replacement or were continent after removal. Overall 55 of 68 patients (81%) were continent. Those with neuropathic bladder dysfunction achieved a continence rate of greater than 90%, although half required sphincter removal initially. When the indication for insertion was stress incontinence, 70% of the patients had the original or a replaced artificial urinary sphincter in situ and 82% were continent. All patients with previous pelvic irradiation had the sphincter removed and urinary diversion was done. CONCLUSIONS: The overall continence rate in female patients after insertion of an artificial urinary sphincter is satisfactory. A satisfactory outcome was achieved in terms of stress incontinence and we would recommend an artificial urinary sphincter after an adequate anti-stress incontinence operation fails. Continence in patients with neuropathic bladder dysfunction is excellent and the artificial urinary sphincter should be considered first line treatment in this group, although the risk of revision surgery is high. Pelvic irradiation is a contraindication to the artificial urinary sphincter in female patients.

Adolescent↗