Biomedical subjects
Publications and source records attributed to R L Vereecken.
Eight older women with stress incontinence caused by intrinsic urethral weakness underwent sling surgery with allogenic fascia lata. The tolerance of the material was excellent. In 1 case a secondary release of the fixation on the pecten was necessary because of too much tension; in the other cases the evolution was uneventful and resulted in perfect continence lasting for at least 2 years of follow-up.
The influence of posture of the pelvis and straining on urinary flow was investigated in 21 normal women, mainly physiotherapists, who were asked to urinate on an uro-flow chair at their usual time and frequency. Subjects were at random instructed to urinate in five different test situations: anteversion, anteversion with straining, retroversion, retroversion with straining, and forward bending without straining. The urinary-flow parameters investigated were volume, peak flow, time to peak, peak-to-end time, total time, and mean flow. The analysis was done by means of analysis of variance but only for micturition volumes >150 mL. The morphology of the urinary-flow curves was examined for the presence of irregularities and increasing (after top) or decreasing (for top) curve tops and after-dribbling. Results demonstrated no significant differences for peak flow, total time, and mean flow in the anteversion, retroversion, and the forward-bending position. This holds for test situations and re-test controls. However, straining increased the peak flow and mean flow rates in all positions and in all women, whereas it reduced the total voiding time. The voided volumes were lowest in anteversion. Irregularities were less frequent in the forward-bending position. It can be concluded that the forward-bending position is the most preferable urinating position to relax the pelvic floor muscles. Neurourol. Urodynam. 19:3-8, 2000.
The requirements for reliable urodynamics are standardized techniques, including uniform pressure sensors, filling rates, position and posture during the investigation, and uniform diuresis. Physiological variations in flow and urethral pressure profile (UPP) (menstrual cycle, intensity of coughing, circadian variations) must be considered. Parameters of the UPP (maximum (closure) urethral pressure, pressure-transmission ratio and leak-point pressure) are useful if interpreted with caution. Uninhibited detrusor contractions are more frequently recorded in ambulatory urodynamics, and range from 'subthreshold' to very strong. No quantification formulae correlate with subjective symptoms or degree of urge (incontinence). Mixed incontinence can make the results of surgery worse, but do not so necessarily. Postoperative dysuria cannot be predicted from urodynamics, as surgical factors are more important. Electromyography is not useful in non-neurogenic female incontinence. For routine nonneurogenic incontinence extensive urodynamic testing can be reduced to one pressure measurement; more complicated cases must be tested by a physician with large practical experience and a theoretical background.
OBJECTIVES: To evaluate whether extensive trigonal surgery for duplicated kidneys is harmful for later bladder and urethral function. METHODS: Of 201 surgically treated children with kidney and ureteral duplication, 145 were followed up for at least 1 year. The mean follow-up was 5 years (range 1 to 15), and all patients were at least 7 years old at the date of their last follow-up visit. Trigone surgery was performed in 105 children; bilateral trigonal surgery in 26, unroofing in 25, and total excision in 5. On all later consultations, the presence of infection, voiding habits, continence pattern, and ultrasound findings for residual urine volume and kidney function were noted. Children with recurrent urinary tract infection or dysfunctional voiding for more than 2 years underwent a urodynamic examination. RESULTS: Nine children, of whom five were boys, had nocturnal enuresis only. Eight patients had day and nighttime wetting. Seven of the 8 patients had recurrent urinary infections; urodynamic evaluation revealed a high compliance (with residual urine) in three of these children and four had detrusor instability. One girl had an irregular bladder neck, with stress incontinence. All reflux, whether surgically or conservatively treated and also three of four occurring de novo, disappeared within 1 year after surgery. In the group without voiding dysfunctions, seven cystitis and five pyelonephritis attacks occurred. CONCLUSIONS: Neither extensive trigonal surgery nor pre-existing trigonal deformation by ureteroceles provokes later bladder dysfunction.
OBJECTIVE: To evaluate the mechanism and significance of the after-contraction, recorded in bladder pressure by urodynamics, at the end of micturition. PATIENTS AND METHODS: The urodynamic recordings showing an after-contraction of the detrusor in 65 patients of all ages and with a variety of pathologies were re-examined. Special attention was directed to the anal or urethral sphincter needle electromyographic activity and to the monitored urethral pressure, to determine any relationships with the patterns of detrusor pressure. RESULTS: An after-contraction was noted in 61 patients with detrusor instability and in 11 with urethral instability. In 59 patients it was evident that the after-contraction, i.e. a renewed increase in detrusor pressure during the declining contraction, correlated with a sphincter contraction preceding it by a fraction of a second. Similar increases in detrusor pressure were apparent in patients with detrusor-sphincter dyssynergia throughout voiding. In six patients the relationship was less clear mainly because there were artefacts in the curves. CONCLUSION: The after-contraction arises by a sudden stopping of the outflow of urine, provoked by a sphincter contraction. This may occur by involuntary dyssynergia or by an early voluntary interruption of the voiding stream. The 'milk back' of urine from the proximal urethra to the bladder and the inhibited detrusor contraction (if the perineal contraction is prolonged) may cause some postvoid residual urine. It occurs mainly in the presence of detrusor and/or urethral instability.
PURPOSE: We monitored detrusor and urethral behavior during bladder filling in girls with dysfunctional voiding (incomplete perineal relaxation) to determine the causes of this pathological condition. MATERIALS AND METHODS: In 15 girls without neuropathy but with a staccato voiding pattern in whom symptoms of urinary tract infection and urge incontinence were refractory to treatment we recorded urethral and bladder pressure, and anal sphincter needle electromyography throughout slow bladder filling. RESULTS: Urethral instability was observed in 8 of the 15 girls as urethral pressure decreases with short periods of electromyography silence (6) or as intermittent urethral pressure increases with short perineal spasms (2). Detrusor instability was noted in 12 girls, while bladder pressure was normal in 1 and hypoactive in 2. In 6 cases of an unstable bladder urethral pressure decreases with silent electromyography periods were also noted. In 1 case low basic urethral pressure had short periods of increased pressure with electromyography bursts. In another case high compliance bladder uninhibited sphincter contractions were noted throughout filling. CONCLUSIONS: Dysfunctional voiding is a misleading term since a pathological condition is also present during the bladder filling phase. Frequently observed detrusor and urethral instability may explain the urge sensation during filling and the staccato voiding phase.
OBJECTIVES: The evolution of clinical presentation, age of surgery and therapeutic approach of obstructive nonrefluxing megaureters (OMU) in children throughout the years has been retrospectively evaluated. METHODS: 78 children with 92 stenotic ureterovesical junctions (UVJ) were reviewed. 66 underwent surgery at a median age of 20 months, after a median of 10.5 months of conservative treatment with prophylactic antibiotics. 21 OMU were diagnosed prenatally, 71 because of symptoms at later age. 15 ureters (12 children) (24% in the prenatal, 14% in the second group) were treated in a conservative way for 2 years with antibiotics. In the prenatal group 33% needed a reimplantation with tailoring and 10% without tailoring while in the other group the figures are reversed: 39% without and 21% with tailoring. 28% in the prenatal group and 17% of the second group were reimplanted at a mean of 15 months after a primary cutaneous ureterostomy. Three of 5 ureteroceles were treated by endoscopic incision; 4 had an immediate nephroureterectomy. The mean follow-up is >70 months. RESULTS: By prenatal diagnosis the number of conservatively treated cases increased from 14 to 24%. Indications for surgery remained unchanged: recurrent infection and poor kidney function. Both approaches resulted in stabilization of pretreatment renal function; nearly half of the DMSA scans showed a R:L difference of >20% at follow-up. Ureterostomy for infected deteriorating kidneys rapidly ameliorated the function and resulted in shrinking of the ureteral diameter making tailoring at reimplantation unnecessary. One of the 3 endoscopically incised ureteroceles required later reintervention. CONCLUSIONS: Male:female (3:1), left:right (2:1) prevalence and high associated urological (30%) and nonurological (19%) pathology is found. Unsatisfactory reliability of tests for obstruction diagnosis and a referral bias explains the larger number of conservatively treated ureters in the prenatal group. Despite prenatal diagnosis, the age for surgery was not altered since the indications remained identical. Most OMU can be treated by a simple or tailored reimplantation of the ureter after resection of the stenotic segment. A temporary ureterostomy in small children with refractory infections restores function and avoids the necessity for tailoring at final reconstruction. One of 3 endoscopically incised ureteroceles needed surgery at a later stage. DMSA shows stable function after reimplantation.
An ambulatory urodynamic examination was performed on 28 non-neurogenic incontinent patients in whom classical cystometry could not confirm objectively the history and clinical diagnosis of urinary incontinence. In 12 of 13 stress-incontinent patients, real leakage could be demonstrated. Of 15 patients with mixed incontinence, bladder instability was found in 8 and urethral instability in 2. Voiding detrusor pressures in ambulatory measurements were approximately 10 cm H2O higher than in classical cystometry, although the voided volumes were lower. Advantages and pitfalls of ambulatory detrusor pressure monitoring are discussed.
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From an analysis of 202 patients and a careful literature analysis we conclude that pathological urethral instability should be differentiated from physiological urethral pressure variations by the following criteria: a pronounced amplitude of at least one third of the maximum urethral pressure variations by the following criteria: a pronounced amplitude of at least one third of the maximum urethral closure pressure (usually > 25 cm H2O), a short duration (1-5 s), a simultaneous inhibition of the electromyographic activity in urethral and (or) anal sphincter, and the occurrence of the phenomena starting at the beginning of bladder filling (100 ml).
The 1.5- to 8-year results of endoscopic injection of polytetrafluoroethylene for reflux are described. We obtained a 70% complete and long-lasting success rate after a single injection. More than the degree of reflux, the configuration of the ostium determines the results. Implications of the product in the later life of the children are discussed.
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Therapy of children with myelomeningocoele should achieve a double goal: on the one hand, obtain continence and, on the other hand, preserve kidney function without complications. The first goal is a social and psychological one, the latter is a vital one.
In 150 children with enuresis following protocol was applied: a detailed questionnaire, a voiding chart, clinical examination, ultrasound of the kidneys, and uroflow. A tentative treatment based on the flowchart shown in the paper is installed. If after 4-5 weeks no amelioration is observed observation is completed by a urodynamical examination and a permictional urethocystography and the treatment adapted to the results. On this bases each enuresis case could be categorized in one of 4 groups with typical clinical and urodynamical characteristics requiring a specific treatment. The study shows that by an appropriate selective treatment including physical and psychological training and medication nearly all children can get dry.
In 61 children with myelomeningocele urodynamic, radiological and clinical data are correlated. Bladder hyperactivity (low compliance and instability) was present in 77% of the cases. No correlation was observed with the clinical neurological level. However impairment of renal function by hydronephrosis or reflux occurred in 19 of the 33 cases presenting a bladder hyperpressure of more than 40 cm of water for bladder filling volumes lower than the bladder capacity accepted as normal for the children's age. Two thirds of urinary infections occurred in the children with hyperactive bladders. Detrusor-sphincter dyssynergia is observed in only 29% of cases.
A computerized method for urethral pressure measurement along the whole length and at every angle of the urethra is presented. The main advantage is the exact study of physiological versus artificial factors in pressure distribution in the urethra. Details of the technique are presented.
Different types of dysfunctional voiding are described and correlated with psychological characteristics and sexual dysfunctions. Motoric as well as sensoric urge incontinence seems to be more frequently associated with psychological problems than stress incontinence and a psychosomatic therapy often results in cure without any surgery. A multidisciplinary approach to the problem is stressed.
The sexual activity of 153 patients was compared before and three years after transurethral or open prostatectomy. A significant decrease of sexual activity was noted. Multifactorial causes are responsible such as age, general physical and psychological conditions, partners attitudes.