Biomedical subjects
Publications and source records attributed to A R Mundy.
Thirty-one previously diverted patients with various complex lower urinary tract problems have been undiverted with simultaneous reconstruction of the anorectum and vagina when these structures were also affected. No patient was denied undiversion on the basis of pelvic pathology. The only contraindications were a lack of motivation and when the patient's general condition, intelligence and mobility made it an unrealistic proposition.
Fifteen potent men with T3 M0 transitional cell carcinoma of the bladder underwent a technique for cystoprostatectomy designed to preserve the innervation of the distal sphincter mechanism and the corpora cavernosa, and substitution cystoplasty. All patients had previously had radiotherapy. When the neurovascular bundles were seen to be preserved all patients were continent by day (although one had objectively demonstrable stress incontinence) and 60% were potent. Damage to the neurovascular bundles was usually associated with impotence and a degree of stress incontinence, although the latter was correctable by implantation of an artificial sphincter. Cystectomy need not necessarily lead to an abdominal stoma or to impotence.
To assess the effectiveness of the surgical correction of vesico-ureteric reflux, current renal function was determined in 56 children with scarred kidneys who had undergone ureteric reimplantation between 1978 and 1983. The children were aged between 2 and 15 years, had no coexisting urological disease and a glomerular filtration rate (GFR) of less than 90 ml/min/1.73 m2. In the 32 patients who had bilateral reimplantation of ureters draining bilaterally scarred kidneys the improvement in GFR following surgery was highly significant (P less than 0.001), with improvement occurring in 75%. The greatest improvement was in patients where the GFR was less than 50 ml/min/1.73 m2 (29%). Individual kidney GFR was estimated in 42 kidneys and 81% improved after surgery. This improvement was highly significant (P less than 0.001).
A simple endoscopic technique for the infiltration of pelvic plexuses with phenol is described. The results suggest that this is a useful technique in the management of detrusor hyperreflexia and for the older patient with detrusor instability when standard conservative measures have failed. It is contraindicated in male patients because of the risk of impotence.
The effect of atropine on the isometric contractile response of isolated human detrusor muscle strips to electrical field stimulation has been studied. A 94.1% reduction in the response in the presence of tetrodotoxin demonstrated the neuronal nature of the stimulus. Atropine caused a 92.7% inhibition of the response. It was concluded that the nerve-mediated stimulus in human detrusor is cholinergic in nature and that "atropine resistance" does not occur in man.
The distribution of nerves containing vasoactive intestinal polypeptide (VIP) in the hyper-reflexic neuropathic bladder was investigated using immunocytochemistry and radioimmunoassay. Biopsy specimens were taken from the bladders of 21 patients with urodynamically proven detrusor hyper-reflexia and from 20 control patients with no urodynamic abnormality. The results showed a reduction in the number of VIP immunoreactive nerves and a reduction in VIP concentration in the hyper-reflexic bladder when compared with control samples.
Forty patients with refractory urge incontinence were treated by "clam" ileocystoplasty. Thirty patients were cured of their symptoms and are voiding spontaneously, six were cured of their symptoms and are on clean intermittent self-catheterisation and four had their symptoms significantly improved by the operation. Bladder compliance is usually improved by the operation and detrusor instability is either abolished or reduced to an insignificant level, but voiding dysfunction is a common post-operative problem and must be identified and treated.
Four hundred and two videourodynamic studies were performed on 207 children with neuropathic vesicourethral dysfunction due to myelomeningocele. The children were divided into three groups (contractile, intermediate and acontractile) according to the urodynamic behaviour of their bladders, and the behaviour of the bladder neck and distal sphincter mechanism was assessed in each group. The bladder neck may be competent or incompetent in children with contractile bladders but is never obstructive, and is always incompetent in children with either intermediate or acontractile bladders at their usual bladder volumes. The distal sphincter mechanism is nearly always dynamically obstructive (detrusor-sphincter dyssynergia) in children with contractile bladders but is rarely if ever incompetent, whereas in children with intermediate or acontractile bladders, both (static) distal sphincter obstruction and sphincter weakness incontinence exist to some degree, although the predominance of one of these may mask the existence of the other unless it is specifically looked for or some therapeutic manoeuvre unmasks it. The main conclusion from this study is that, with the possible exception of those few children with more minor partial cord lesions, dysfunction of one or both sphincter mechanisms is the rule in congenital cord lesions.
In a study of 75 isolated human detrusor muscle strips, spontaneous contractions and an associated sustained rise in basal tension were observed in 43 (57%). Vasoactive intestinal polypeptide (VIP) caused significant reductions in the frequency and amplitude of spontaneous contractions and a fall in basal tension. The results suggest that VIP may have a role as an inhibitor of spontaneous activity in the human detrusor.
Sixty-one patients with lower urinary tract neuropathy were treated surgically, either to achieve continence or to prevent or arrest renal deterioration, or both. Most were myelodysplastics and all but two were ambulatory. Three techniques were employed, depending on the detrusor/sphincter behaviour and the sex of the patient: enterocystoplasty alone, with or without selective sphincterotomy and/or intermittent self-catheterisation; total sphincter ablation and an artificial sphincter; or, most commonly, enterocystoplasty combined with sphincter ablation and an artificial sphincter. Continence was achieved in 58 patients, though nocturnal enuresis was sometimes a problem; renal deterioration was arrested in 13 of 14 patients and renal function remained stable in all of the other patients.
The unstable bladder is a common clinical problem of uncertain etiology. Current in vitro studies of unstable human detrusor samples show differences in behavior and response to pharmacologic agents from normal detrusor. The fundamental urodynamic abnormality is the occurrence of involuntary detrusor contractions, which cause the cardinal symptom of urgency. The incidence of other symptoms is determined by the functional bladder capacity and the patient's ability to resist the unstable contractions. Having excluded outflow obstruction as a causative or associated factor, empirical treatment may reasonably be started on the basis of the findings of a 48-hour voided volume chart, reserving full urodynamic investigation for patients who fail to respond to treatment as expected. For those with minimal urodynamic dysfunction, bladder drill is the treatment of choice; when this fails or is inappropriate, drug treatment with oxybutynin is indicated, supplemented by other drugs when appropriate. When these standard conservative measures fail, then transvesical injection of the pelvic plexuses with phenol gives worthwhile results and is a trivial procedure. If this fails, and in men in whom the phenol procedure is contraindicated, "clam" ileocystoplasty is usually if not always curative.
The unstable bladder is a common clinical problem of uncertain aetiology. Current in vitro studies of unstable human detrusor samples show differences in behaviour and response to pharmacological agents from normal detrusor. The fundamental urodynamic abnormality is the occurrence of involuntary detrusor contractions which cause the cardinal symptom of urgency. The incidence of other symptoms is determined by the functional bladder capacity and the patient's ability to resist the unstable contractions. Having excluded outflow obstruction as a causative or associated factor, empirical treatment may reasonably be started on the basis of the findings of a 48-hour voided volume chart, reserving full urodynamic investigation for patients who fail to respond to treatment as expected. For those with minimal urodynamic dysfunction, bladder drill is the treatment of choice; when this fails or is inappropriate, drug treatment with oxybutynin is indicated, supplemented by other drugs when appropriate. When these standard conservative measures fail, transvesical injection of the pelvic plexuses with phenol gives worthwhile results and is a trivial procedure. If this fails, and in men in whom the phenol procedure is contraindicated, 'clam' ileocystoplasty is usually if not always curative.
Cytologic features indicative of malignancy were related to the subsequent rate of tumor recurrence in 50 patients with T1 and T2 transitional cell carcinoma (TCC) of the bladder. All patients with T1 disease in whom frequent recurrences developed had more than 15 per cent malignant-looking (ML) cells in their original biopsy. In patients with less than 15 per cent ML cells recurrences developed infrequently. All patients with T2 disease who had more than 15.5 per cent ML cells subsequently had a poor prognosis, whereas those with less than 15.5 per cent ML cells had a good prognosis.
One hundred and sixteen patients with detrusor instability, detrusor hyper-reflexia or bladder hypersensitivity who had failed to respond to standard conservative methods of management were treated by transvesical infiltration of the pelvic plexuses with phenol. A satisfactory response was obtained in detrusor hyper-reflexia (82%), in detrusor instability in patients over 55 years of age (69%) and in idiopathic bladder hypersensitivity (68%). The response rate was much less satisfactory in detrusor instability in patients less than 55 years of age (14%) and when there was a definable cause for bladder hypersensitivity (0%).
The Brantley Scott artificial urinary sphincter (AUS) is a safe, effective and relatively trouble-free device for the control of sphincter weakness incontinence. Suitable patients should have no other urodynamic dysfunction or have had such a dysfunction corrected or controlled. Patients with post-prostatectomy incontinence pose no problems in selection, although as a group they are the most prone to develop complications. Pure stress incontinence does not warrant implantation of an AUS except in very rare instances. In neuropathic dysfunction the AUS is one of several treatment options for the correction of incontinence and is most effectively used as such. In all patients, thorough pre-operative videourodynamic evaluation is essential to get the best results and therefore to justify the infective and mechanical risks and the expense of the device.
One hundred and four patients with urge incontinence associated with detrusor instability who had failed to respond to standard conservative treatment were treated by a modified bladder transection procedure. Initially 74% were symptomatically cured, 14% were improved and 12% were failures. At 2 to 5 years after operation these results were 65%, 19% and 16% respectively. There was no significant morbidity and no mortality. Bladder transection is still a useful method of treatment for the refractory patient with detrusor instability, although improvements in conservative treatment have reduced the need for it.
The possible involvement in idiopathic detrusor instability of a newly discovered type of autonomic nerve containing vasoactive intestinal polypeptide (VIP) has been studied. Immunocytochemistry and radioimmunoassay, using specific antibodies against VIP, were carried out on 20 biopsy specimens from the bladders of patients with detrusor instability and 20 specimens from control patients. The concentration of VIP in the unstable bladders was found to be markedly reduced from 36.52 +/- 4.8 pmol/g (mean +/- SEM) to 7.62 +/- 1.84 pmol/g (P less than 0.01). The number of VIP immunoreactive nerves was greatly decreased in all of the layers but particularly in the muscle layer of the unstable bladder in comparison with the controls. These findings may provide important information about the mechanism of this disorder.