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Biomedical subjects

A R Mundy

Publications and source records attributed to A R Mundy.

At least 19 recordsLinked to original sources
PubMed1992

Stamey-Martius procedure for severe genuine stress incontinence.

There are few options now available to treat patients with severe genuine stress incontinence caused by urethral failure. These patients usually have a low maximum urethral closure pressure (less than 20 cm of water) and anterior vaginal wall scarring caused by previous surgery. In 32 such patients we used the Martius fat pad insertion procedure, in addition to the Stamey procedure, and achieved a 91% symptomatic success rate over a mean 13-month follow-up period. Because of its simplicity, reliability and low morbidity, we recommend this procedure in this difficult group of patients before performing a sling procedure or insertion of an artificial urinary sphincter.

Adipose Tissue↗
PubMed1992

Role of the artificial urinary sphincter in the treatment of stress incontinence in women.

The artificial urinary sphincter (AUS) is rarely indicated in the treatment of women with stress incontinence because most of these women have deficient urethral support rather than pure sphincter weakness and the AUS is a treatment specifically for pure sphincter weakness. The procedure is contraindicated after pelvic radiotherapy and after previous sling surgery because of the high incidence of cuff erosion. Otherwise the artificial sphincter gives excellent results comparable to those seen in men with post-prostatectomy incontinence and much better than in neuropathic bladder dysfunction.

Adult↗
PubMed1992

Calcium balance, growth and skeletal mineralisation in patients with cystoplasties.

Twelve adult female patients and 16 children who had undergone augmentation cystoplasty at least 2 years previously were studied to assess calcium balance and skeletal mineralisation. The serum and 24-h urinary calcium levels were measured and arterial blood gas analysis was performed in all patients. In children, skeletal mineralisation was assessed by serial study of their growth charts, comparing their growth centiles before and after cystoplasty. In adults, skeletal mineralisation was assessed by dual photon absorptiometry (DPA). As previously reported, all patients had a metabolic acidosis, usually with respiratory compensation. Serum and 24-h urinary calcium levels were all within the normal range. Growth charts of the 6 children with colocystoplasties showed an average of 20% reduction in growth potential in 3 of them. Growth charts in the 10 children with ileocystoplasties did not show any change in growth pattern. DPA bone scans in adults were all normal. These results suggest that if calcium is mobilised from bone in patients with a cystoplasty as a result of the metabolic acidosis, then it is reabsorbed from the bladder by the gut segment after an ileocystoplasty; colonic segments are less efficient than ileal segments, however, so that after a colocystoplasty skeletal demineralisation or a reduction in growth potential is more likely.

Absorptiometry, Photon↗
PubMed1992

Cystoprostatectomy and substitution cystoplasty for locally invasive bladder cancer.

The results and long-term follow-up of 48 patients undergoing cystoprostatectomy and substitution cystoplasty for T2/3, M0 transitional cell carcinoma of the bladder are reported. There was no operative mortality but 1 early death from thromboembolic disease. Thirty-six patients are alive with a mean follow-up of 57 months (range 12-120). Eleven patients died of disseminated disease. Thirty-one patients (64%) regained normal continence by day and night and a further 8 were dry by day but incontinent at night; 9 patients underwent further surgery for incontinence and this was successful in 8, giving an overall continence rate of 79% and a day-time continence rate of 98%. Of the 38 patients claiming to be potent pre-operatively, 24 (63%) were potent post-operatively. Nerve-sparing cystoprostatectomy and substitution cystoplasty is a safe alternative to a "standard" cystectomy and ileal conduit diversion in a selected group of men undergoing radical surgery for invasive bladder cancer and it achieves its aims of preserving continence and potency in the majority of patients.

Adult↗
PubMed1991

Lower urinary tract reconstruction in patients with bladder exstrophy after failed primary treatment in early childhood.

The results of neonatal surgery for bladder exstrophy are not very satisfactory. A significant percentage of patients present in later childhood or adolescence for correction of their residual deformities. We have reconstructed 26 patients, correcting their entire urogenital and cosmetic deformity in a one-stage procedure. The results show that one-stage total reconstruction is possible and is preferable to serial correction of the various individual abnormalities. The principles of surgical reoperation in adolescence are the same as those now established for the primary correction in neonatal life.

Adolescent↗
PubMed1991

The effect of cromakalim on the normal and hyper-reflexic human detrusor muscle.

Cromakalim is a benzopyran derivative which relaxes smooth muscle, probably by opening membrane potassium channels. This study tested the effect of cromakalim on spontaneous, electrically induced and pharmacologically induced contractile activity of normal and hyper-reflexic human detrusor muscle samples. All 3 types of contractile activity were reduced in the presence of cromakalim. A preliminary clinical trial of cromakalim was conducted, the results of which also suggest that this type of drug may have a significant role in the treatment of detrusor instability and hyper-reflexia.

Acetylcholine↗
PubMed1991

Problems in the surgical treatment of interstitial cystitis.

Two series of patients with histologically proven interstitial cystitis that was unresponsive to hydrostatic bladder distension and intravesical chemotherapy with dimethyl sulfoxide have been studied. In the first series 24 patients were treated by subtotal cystectomy and substitution cystoplasty without further consideration; 8 of these 24 patients had persistent frequency due to active disease in the remaining trigone and/or urethra and in 2 cases this was severe. Because of this experience the second group of patients had routine biopsy of the trigone and assessment of urethral sensation as part of the initial assessment. In those in whom the trigone was unaffected, treatment was unchanged. If the trigone was affected, total cystourethrectomy was performed with substitution cystourethroplasty unless the patient chose or was advised to avoid surgery altogether or to have a simpler option such as conduit or continent urinary diversion. Trigonal biopsies should be part of the routine assessment of all patients being considered for surgery, since residual active disease is a major cause of dissatisfaction after subtotal cystectomy and substitution cystoplasty.

Adult↗
PubMed1991

The role of delayed primary repair in the acute management of pelvic fracture injuries of the urethra.

The principal aim of management of the ruptured urethra should be to do everything possible to reduce the long-term complication rate and this applies principally to stricture formation. By far the most difficult complication to treat is severe distraction; thus the aim of early management should be to recognise and correct severe distraction injuries. Delayed primary repair at 7 to 10 days is recommended for this problem. The aim is not to prevent a stricture occurring but to make sure that if it does occur it is easily treatable.

Adolescent↗
PubMed1990

ThioTEPA pharmacokinetics during intravesical chemotherapy and the influence of Tween 80.

A pharmacokinetic study of randomised crossover design was carried out in which eight patients with recurrent stage pTa or pT1 transitional cell carcinoma of the bladder were given thioTEPA (30 mg) in distilled water or in 10% (v/v) Tween 80 (30 ml) intravesically for 2 h, followed 3 months later by the alternative treatment. ThioTEPA and its primary metabolite, TEPA, were measured in plasma and urine using a sensitive and specific chromatographic assay. Large differences between patients were observed in the proportion of thioTEPA absorbed, ranging from 20%-78%. Peak plasma levels of thioTEPA were observed within 1 h of intravesical administration. By 2 h after administration the plasma levels of TEPA were similar to those of thioTEPA and, in contrast to those of the parent compound, remained at a similar level over the next 4 h. The rate of absorption of thioTEPA was not influenced by Tween 80, but it did cause statistically significant increases in mean peak plasma levels (from 101 to 154 ng/ml) and mean AUC values (from 0.376 to 0.496 micrograms h per ml) and a decrease in the mean half-life (from 1.83 to 1.25 h). To obtain plasma levels similar to those achieved after instillation with thioTEPA alone, the dose should be reduced with Tween 80.

Absorption↗
PubMed1990

Surgical management of the congenital neuropathic bladder.

We have previously described 3 types of lower urinary tract dysfunction in the congenital neuropathic bladder--contractile, intermediate and acontractile--accounting for 35, 40 and 25% of patients respectively. Subsequent urodynamic and surgical experience has shown that the intermediate type is commoner and the acontractile type less common than was thought. The contractile group accounts for 31% of patients and rarely requires surgery (a "clam" ileocystoplasty). The acontractile group accounts for only 9% but more commonly requires surgical treatment, usually the implantation of an artificial urinary sphincter (AUS). The intermediate group accounts for 60% of patients and usually requires surgery. If there is no significant sphincter weakness incontinence, a "clam" ileocystoplasty alone is performed; if there is sphincter weakness, a "clam and a cuff" procedure is performed with implantation of the remainder of the AUS at a later date, if required.

Humans↗
PubMed1989

The density of cholinergic and alpha and beta adrenergic receptors in the normal and hyper-reflexic human detrusor.

The density of cholinergic and of alpha and beta adrenergic receptors was measured in samples of normal and hyper-reflexic human detrusor muscle. There was a significant reduction in the density of cholinergic receptors and a significant increase in the density of alpha adrenergic receptors in the hyper-reflexic samples as compared with normal. There was no difference between the two groups in the density of beta adrenergic receptors.

Female↗
PubMed1989

Urethral substitution in women.

A series of 30 female patients underwent total urethral substitution for a variety of conditions, usually urogenital sinus abnormalities or post-irradiation vesicourethrovaginal fistulae. Five different techniques were used: bladder flap neourethroplasty, neourethroplasty using a urinary tract remnant, vaginal/urogenital sinus neourethroplasty, pedicled labial skin tube neourethroplasty and colonic substitution neourethroplasty with synchronous implantation of an artificial sphincter. Bladder flap neourethroplasty is appropriate if the bladder size is adequate and if the bladder neck is incompetent, but stress incontinence is a common complication which must be anticipated and dealt with proleptically. Vaginal/UG sinus neourethroplasty is preferred if the bladder neck is competent enough to preserve continence. When no other tissue is available, particularly after radiotherapy, a pedicled labial skin tube neourethroplasty gives the best results. Colonic substitution with the implantation of an artificial sphincter is not satisfactory. Any surgically created neourethra should be wrapped with either labial fat pads or omentum and, in the absence of a competent bladder neck, with an artificial sphincter cuff to support the urethra and to prevent it telescoping, and for use as a back-up if continence is not adequate.

Adolescent↗
PubMed1989

Metabolic complications of cystoplasty.

A series of 48 patients with intestinal segments incorporated into the urinary tract underwent assessment of acid-base and electrolyte balance. All patients had abnormal blood gas analyses, usually a metabolic acidosis with respiratory compensation; 33% had hyperchloraemia. Radioisotope studies using sodium, potassium and bromine showed that all were absorbed and that absorption was unaffected by renal function. The results suggest that all such patients, but particularly women and children, may be at risk of the secondary effects of chronic acidosis, especially skeletal demineralisation, unless some compensatory mechanism is working to offset the effects of the acidosis.

Acidosis↗
PubMed1989

The dissolution of urinary mucus after cystoplasty.

Three agents have been tested for mucolytic activity to prevent or treat difficulties in bladder emptying following augmentation and substitution cystoplasty, particularly in patients emptying by intermittent self-catheterisation. Carbocysteine produced precipitation of mucus, which was found not to be helpful. N-acetylcysteine and urea both dissolved mucus, but urea proved to be more effective.

Acetylcysteine↗