Biomedical subjects
C R Woodhouse
Publications and source records attributed to C R Woodhouse.
The gynaecology of exstrophy.
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What is new in urinary diversion.
There have been some suggestions for changes in technique and investigations of the quality of life. As experience has grown, there have been increasing numbers of reports of complications. Careful attention to technique, especially in nerve-sparing cystectomy and orthotopic cystoplasty may reduce the rate of incontinence. Increasing awareness of quality of life issues should improve preoperative counselling of patients, especially those whose underlying condition is not life-threatening.
Re: Strategies for reconstruction after unsuccessful or unsatisfactory primary treatment of patients with bladder exstrophy or incontinent epispadias.
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The transverse ileal tube as second-line modification of the Mitrofanoff principle.
With the advantages of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high mobility of the tube), minimized risk of stone formation (no use of staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice for the Mitrofanoff conduit. A longer period of follow-up is needed to determine whether it deserves a permanent place in the reconstructive surgeons' repertoire.
Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube.
PURPOSE: Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique. MATERIALS AND METHODS: From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube. RESULTS: Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization. CONCLUSIONS: With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.
Sexual function in boys born with exstrophy, myelomeningocele, and micropenis.
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Invasive carcinoma in bladder exstrophy with transitional, squamous and mucus-producing differentiation.
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Modified ureterosigmoidostomy (Mainz II)--technique and early results.
OBJECTIVE: To assess the surgical method and results at 3 months of ureterosigmoidostomy modified by reconfiguration of the rectum to make a low-pressure reservoir. PATIENTS AND METHODS: Over the last 8 years, patients undergoing lower urinary tract reconstruction have been followed using a written protocol; the data from patients undergoing a modified ureterosigmoidostomy were retrieved for a retrospective analysis. Two groups of patients were defined: in group A, 15 patients underwent cystectomy and diversion by modified ureterosigmoidostomy and in group B, four patients already had a conventional ureterosigmoidostomy which was incontinent, and the rectum was reconfigured to improve control. The incidence of complications and causes of incontinence were assessed. RESULTS: The rectum was reconfigured by longitudinal incision and transverse closure in a 'U' fashion (Mainz II) in 17 patients, and augmented with ileum in two. There were no surgical complications. In group A all patients were continent at 3 months and in group B only two of four were continent; one patient in group A subsequently became incontinent. All incontinence was caused by chronic retention and overflow. There were no cases of pyelonephritis during follow-up to 29 months and no ureteric reflux was detected. CONCLUSIONS: Modified ureterosigmoidostomy is a safe method of urinary diversion after cystectomy. A longer follow-up is needed to judge its place compared with other forms of diversion. It has a limited place in the management of incontinence in those with a longstanding conventional ureterosigmoidostomy.
Renal transplantation following renal failure due to urological disorders.
BACKGROUND: Renal allograft outcome, during an 8 year period (1985-1992), has been assessed in 56 renal transplants performed in 55 patients who had end-stage renal failure as a consequence of urological abnormalities. The abnormalities were: primary vesicoureteric reflux (VUR) or renal dysplasia (26 patients); posterior urethral valves (PUV) (15); neuropathic bladders (6); vesico-ureteric tuberculosis (5); bladder exstrophy (3); and prune belly syndrome (1). Six patients had augmented bladders, and eight transplants were performed in seven patients with urinary diversions. RESULTS: Overall, 1 and 5 year actuarial graft survival was 89 and 66%, with mean creatinine of 154 micromol/l +/- 11 (SE) and 145 +/- 9 respectively. Patients with abnormal bladders or conduits (n = 28) had worse graft function than those with normal bladders (n = 28) although graft survival was not significantly different in the two groups at 1 and 5 years: 93 and 75% with normal bladders vs 86 and 57% with abnormal systems. Symptomatic urinary tract infections were common in the first 3 months after transplantation (63%); fever and systemic symptoms occurred in 39% with normal bladders and 59% with abnormal bladders. Urinary tract infection directly contributed to graft loss in six patients with abnormal bladders, but had no consequences in those with normal bladders. CONCLUSIONS: Abnormal bladders must be assessed urodynamically before transplantation, and after transplantation adequacy of urinary drainage must be re-assessed frequently. Prophylactic antibiotics are now given for the first 6 months and urinary tract infections must be treated promptly. With these measures, good results, similar to those of patients without urological problems, can be obtained.
The value of the MACE (Malone antegrade colonic enema) procedure in adult patients.
BACKGROUND: We report our experience with the Malone antegrade colonic enema (MACE) procedure in adult patients suffering from urinary incontinence and intractable constipation with or without fecal soiling. STUDY DESIGN: Since June 1990, the MACE procedure was initiated in 4 female and 12 male patients 14-54 years old (mean age, 29.9 years) with different pathologic conditions (myelodysplasia, n = 7; anorectal anomaly, n = 3; spinal cord lesion, n = 4; neuropathic disease of unclear cause, n = 2). Three surgical techniques were used: reversed and in situ appendix and tapered ileum). Complex simultaneous urologic continence procedures were performed in nine patients. Two patients had undergone previous operations in the lower urinary tract. RESULTS: After 6.6 years of followup (average, 41.7 months), eight patients (50%) were still using the MACE successfully. They were completely clean day and night and were relieved of symptoms of constipation. Eleven complications related to the MACE procedure occurred in seven patients (44%). Eight patients abandoned the procedure for various reasons. The failure rate was higher in chronically constipated patients without fecal soiling. CONCLUSIONS: The MACE procedure is associated with a high failure rate when used in adults, but it may be possible to identify a subgroup of patients in whom the procedure could be beneficial. Success would depend on overcoming technical problems and difficulties with patient compliance.
Multiple frequent recurrences in superficial transitional cell carcinoma of the bladder: is survival compromised by a conservative management strategy?
OBJECTIVE: To examine whether a strategy of bladder conservation is reasonable in patients with multiple frequent superficial recurrences of transitional cell carcinoma (TCC) of the bladder. PATIENTS AND METHODS: Fifty-four patients with pTa/pT1. G1/G2 tumours at diagnosis, with five or more recurrences at two or more cystoscopies within 2 years of diagnosis and a minimum follow-up of 4 years were identified. The patients were categorized according to outcome, i.e. disease settled, continuing high-activity disease and disease progression. RESULTS: Forty-four patients did not progress, of whom 16 continued to have high-activity disease and 28 settled to a lower disease activity. One patient had a cystectomy for superficial disease. Nine patients progressed, six with muscle invasion in the bladder and three elsewhere in the urinary tract. Neither grade nor stage were predictive of recurrence. All but one of the patients with progression had both multicentric tumours at diagnosis and a positive cystoscopy at 3 months. Three patients died from their bladder cancer. CONCLUSION: A policy of endoscopic resections and intravesical chemotherapy or bacille-Calmette-Guèrin, with cystectomy reserved until muscle-invasive disease develops, does not significantly compromise survival in patients with high-activity superficial TCC. Cystectomy for superficial disease is rarely necessary.
The anatomy and reconstruction of the adult female genitalia in classical exstrophy.
OBJECTIVE: To review the anatomy and reconstruction of the external genitalia in adult females born with exstrophy. PATIENTS AND METHODS: Between 1981 and 1995, 47 females (born between 1953 and 1980) were seen in the adolescent clinic at St Peter's Hospital. The notes of 42 were reviewed to obtain data on genital reconstruction and sexual function. When patients were no longer under personal review, a telephone contact was made to obtain further information. RESULTS: The pelvic structures were displaced forwards so that the introitus was a structure of the lower abdominal wall. The clitoris was bifid and the labia were not united anteriorly; the introitus was very narrow. The pubic hair lay on either side of the introitus. Twenty-eight patients had a modified episiotomy and two a vaginoplasty to allow penetrative intercourse. Fifteen patients had a vulvoplasty and a monsplasty. The surgical results were good in all but one case. One patient had partial necrosis of the skin flaps for the monsplasty. All patients who had an episiotomy were able to have intercourse while only four unreconstructed cases could do so. CONCLUSIONS: The genital anatomy in females with exstrophy is abnormal. Reconstructive surgery can improve the appearances and allows penetrative sexual intercourse.
The in situ appendix in the Malone antegrade continence enema procedure for faecal incontinence.
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Markedly delayed linear growth in a child with cloacal exstrophy.
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The Mitrofanoff principle for continent urinary diversion.
The term Mitrofanoff describes a system for making a continent supra-public conduit into any reservoir for self-catheterisation. It requires a narrow tube, the commonest source of which is the appendix. Alternatively, the ureter, the Fallopian tube or a length of tailored intestine may be used. The tube is buried in the wall of the conduit in a tunnel about 5 cm long. There is no statistically significant difference in the results between any patient diagnosis, source of narrow tube or type of reservoir. About 90% of patients are continent. Up to 30% may have conduit complications, particularly stenosis at the skin level. Of the several systems of continent diversion available, the Mitrofanoff seems to be the easiest to learn and the most reliable.
A feasibility study for the non-invasive treatment of superficial bladder tumours with focused ultrasound.
OBJECTIVE: To determine whether high-intensity focused ultrasound can be used to ablate bladder wall tissue using a transabdominal approach in a large animal model, and whether it can be developed as a non-invasive treatment for superficial bladder tumours. MATERIALS AND METHODS: The bladder wall of 25 large white pigs was treated with a 1.7 MHz extracorporeal focused-bowl ultrasonic transducer. Animals were killed either 2 h, 3 days or 4 weeks after treatment and the bladder wall examined macroscopically and histologically. RESULTS: Acute bladder wall damage was detected in 15 of 16 animals at 2 h and in all six animals examined after 3 days. Areas of healing were seen in 10 of 12 animals at 4 weeks. Histological analysis of the treated areas revealed that the urothelium was denuded within 2 h and was associated with an acute inflammatory response in the bladder wall. At 4 weeks, the urothelium had regenerated over a maturing scar. CONCLUSIONS: Focused ultrasound can be used successfully to destroy regions of the bladder wall in a large animal model in vivo.