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Biomedical subjects

S D Boyd

Publications and source records attributed to S D Boyd.

At least 37 records · Page 2Linked to original sources
PubMed1996

Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of continence results and fluorourodynamic findings.

OBJECTIVES: To update continence results and present fluorourodynamic data in 17 female patients undergoing orthotopic lower urinary tract reconstruction with the Kock ileal urethrostomy following cystectomy. METHODS: Continence results, voiding pattern, and overall patient satisfaction were evaluated by means of patient survey. Fluorourodynamic data and abdominal leak point pressures were obtained in 6 patients. RESULTS: Complete daytime urinary continence was reported in 93% of patients, whereas complete nighttime continence was reported by 87% of patients. Fluorourodynamic studies demonstrated excellent neobladder capacity with low reservoir pressure in all cases. Abdominal leak point pressure measurements confirmed normal urethral sphincter function. CONCLUSIONS: Excellent results with respect to urinary continence, voiding pattern, patient satisfaction, and reservoir function can be expected in women undergoing orthotopic lower urinary tract reconstruction.

Adult↗
PubMed1996

Inner-city older blacks have high levels of functional disability.

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner-city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program. DESIGN: Cross-sectional descriptive study. SETTING: Community-based samples. PARTICIPANTS: A population-based sample of 416 older adults living in a 3.5-square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois. MEASUREMENTS: Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups. RESULTS: The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age-gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one-half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one-leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large. CONCLUSIONS: The special attributes of inner-city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans. 44:0000-0000, 1996.

Activities of Daily Living↗
PubMed1996

Complications of the afferent antireflux valve mechanism in the Kock ileal reservoir.

PURPOSE: Since 1982 the Kock ileal reservoir has been the primary form of urinary diversion in patients requiring lower urinary tract reconstruction at our institution. The intussuscepted afferent nipple valve of the Kock ileal reservoir is designed to prevent reflux and protect the upper urinary tract. Problems associated specifically with the afferent antireflux valve have been few. We defined and characterized all complications associated with the Kock pouch antireflux nipple valve. MATERIALS AND METHODS: From November 1984 through July 1992, 802 patients underwent construction of a continent Kock ileal reservoir. All complications associated with the afferent antireflux valve in this group and their management were identified. RESULTS: Overall, 79 of 802 patients (9.8%) had a total of 84 complications of the afferent antireflux valve (10.4%), including formation of stones on staples securing the afferent nipple valve in 42 cases (5.2%), stenosis of the afferent valve in 35 (4.3%) and prolapse of the valve in 7 (0.9%). A total of 81 patients required surgical intervention to correct the afferent valve complication: 56 (7.0%) were treated endoscopically and 25 (3.1%) required open surgical revision. CONCLUSIONS: We report an overall complication rate of 10.4% associated with the afferent antireflux nipple valve in the Kock ileal reservoir. Most complications can be treated endoscopically without difficulty on an outpatient basis with the use of local sedation. With these results, and only a 3% incidence of open surgical correction of all afferent nipple problems, we encourage the continued use of the intussuscepted afferent nipple valve whenever continent urinary diversion is performed.

Adolescent↗
PubMed1996

Transitional cell carcinoma involving the prostate with a proposed staging classification for stromal invasion.

PURPOSE: We investigated the effect on survival of transitional cell carcinoma of the prostatic urethra, ducts and stroma, and determined the difference between prostatic stromal involvement occurring via direct extension through the bladder wall versus stromal invasion arising intraurethrally. MATERIALS AND METHODS: Between August 1971 and December 1989, 489 men underwent radical cystoprostatectomy for transitional cell carcinoma, including 143 (29.2%) identified with prostate involvement by transitional cell carcinoma, in the cystectomy specimen. Patients were separated into 2 groups: 1-19 in whom the primary bladder tumor extended full thickness through the bladder wall to invade the prostate (classified as P4a) and 2-124 in whom prostate involvement arose from within the prostatic urethra. RESULTS: Five-year recurrence-free and overall survival rates were 25 and 21%, respectively, in group 1 versus 64 and 55%, respectively, in group 2. In the 124 patients in group 2 survival rates were similar for those with prostatic urethral tumors or carcinoma in situ and ductal tumors (no stromal invasion). Five-year overall survival rates without and with stromal invasion were 71 and 36%, respectively (p < 0.0001). Transitional cell carcinoma of the prostatic urethra or ducts does not alter survival predicted by primary bladder stage alone. Prostatic stromal invasion arising intraurethrally significantly decreases survival, which varies based on primary bladder stage (64.6% in stage P1, 30.8% in stages P2/P3a and 13.6% in stage P3b, p = 0.0001). P1 bladder tumors with prostatic stromal invasion arising intraurethrally had a significantly higher survival rate than P4a tumors (64.6 versus 21%, p = 0.0001). P3b bladder tumors with stromal invasion had a survival rate similar to that of P4a tumors (p = 0.78). CONCLUSIONS: Prostatic urethral or ductal transitional cell carcinoma does not alter survival determined by primary bladder stage alone and it should not be classified as P4a. Prostatic stromal involvement arising intraurethrally significantly decreases survival predicted by primary bladder stage alone. P1 bladder tumors with prostatic stromal invasion arising intraurethrally have a significantly higher survival rate than P4a tumors and they should be separately classified as P1str. Muscle invasive (P2/P3a) bladder tumors with stromal invasion have a higher survival rate than P4a tumors (no statistical significance) and they should be designated separately (that is P2str). P3b bladder tumors with prostatic stromal invasion arising intraurethrally are indistinguishable from P4a tumors.

Adult↗
PubMed1995

Radical cystectomy for high risk patients with superficial bladder cancer in the era of orthotopic urinary reconstruction.

BACKGROUND: Many patients with aggressive clinically superficial bladder cancer ultimately die of their cancer, due in part to resistance to undergo radical cystectomy. Radical cystectomy is usually curative for patients with pathologic superficial tumors. Orthotopic urinary reconstruction has lessened the morbidity and lifestyle changes in patients after cystectomy, and may increase patient acceptance of cystectomy as therapy for high risk superficial tumors. METHODS: A retrospective analysis was performed on 182 patients with clinically superficial bladder cancer (Ta, Tis, T1) who had radical cystectomy between 1971 and 1989, to determine the incidence of pathologic upstaging and to assess overall survival, cause-specific survival, and recurrence free survival. Indications for cystectomy included failure of intravesical chemo- or immunotherapy, high grade lamina propria invasive tumors, presence of bladder diverticulae, spread of superficial tumors into the prostatic urethra, and endoscopically uncontrollable tumors. RESULTS: Pathologic upstaging to muscle-invasive or metastatic tumors occurred in 34% of patients, and of these, only half remained organ confined. Metastases were present in 8% of patients at the time of cystectomy. Mucosa-confined tumors were upstaged only 19% of the time, whereas tumors demonstrating lamina propria invasion (T1) were upstaged 40% of the time. Pathologic upstaging to muscle-invasive or metastatic disease was significantly associated with a decreased probability of survival (P = 0.042). With a median follow-up of 7.2 years, overall survival was estimated to be 86%, 72%, and 47%, and recurrence free survival 90%, 83%, and 77% at 2, 5, and 10 years, respectively. CONCLUSIONS: Pathologic upstaging to muscle-invasive or metastatic tumors occurs in one third of highly selected patients with clinically superficial bladder cancer who have had radical cystectomy, half of whom have extravesical disease. Survival is significantly decreased in this group of upstaged patients. With the alternative of orthotopic urinary diversion available to most men and women requiring cystectomy, radical cystectomy should be considered a viable alternative to continued conservative measures for selected patients with aggressive superficial bladder tumors.

Aged↗
PubMed1995

Ventral penile curvature following radical pelvic surgery: a variant of urethral manipulation syndrome.

OBJECTIVES: Urethral manipulation syndrome (UMS) describes ventral penile curvature and urethral stricture disease that develop following repeated episodes of urethral manipulation. We describe a variant of this syndrome, in which the presence of an indwelling catheter following radical pelvic surgery led to a marked penile curvature without clinically apparent urethral stricture disease. METHODS: We identified 4 patients in whom ventral penile curvature developed following radical pelvic surgery. Three patients underwent radical retropubic prostatectomy and the fourth patient underwent radical cystoprostatectomy with creation of a neobladder to the urethra. All were treated with 3 weeks of catheter drainage postoperatively. Each patient reported straight erections prior to surgery. RESULTS: These patients came to prosthesis surgery between 7 months and 3 years after their pelvic procedure. Each patient was noted to have ventral penile curvature when artificial erection was induced. Curvature was secondary to scarring between the anterior corpus spongiosum and the overlying ventral tunica albuginea in the mid- to proximal penile shaft. It was necessary to mobilize the urethra off the corpora and to incise the scarred tunica to obtain a satisfactory result at the time of prosthesis placement. In 3 cases, GoreTex was needed to bridge the corporeal defect. CONCLUSIONS: These cases represent a variant of UMS in which catheter drainage leads to scarring of the ventral tunica albuginea, resulting in ventral penile curvature. In view of the increasing number of radical pelvic procedures being performed, this potential complication must be recognized, as aggressive corporeal reconstruction with urethral mobilization is needed if subsequent prosthesis surgery is undertaken.

Cicatrix↗
PubMed1995

Post-operative risk factors associated with artificial urinary sphincter infection-erosion.

OBJECTIVE: To determine the incidence of infection-erosion associated with the implantation of artificial urinary sphincters (AMS 800) in a high-risk group of patients (post-major pelvic surgery/radiotherapy), and to emphasize the commonly neglected risk factors associated with this complication. PATIENTS AND METHODS: One-hundred-and forty-five male patients aged 55-79 years (mean 71) who had had an AMS 800 artificial sphincter implanted between January 1987 and November 1993 were reviewed. All patients had undergone meticulous surgical technique, intra-operative shave and rigorous scrub, and were given peri-operative antibiotics. The mean follow-up was 34.3 months (range 1-83). RESULTS: Infection-erosion occurred in 13 patients (9%), of whom 10 are currently available for follow-up. One patient died of his underlying disease (bladder cancer) and two were lost to follow-up. All 13 patients had undergone radical pelvic surgery (radical retropubic prostatectomy, radical cystectomy and abdominoperineal resection); seven patients had also received radiation therapy. Cultures of the infected AMS 800 devices revealed a pleomorphic group of organisms, specifically enteric, Gram-positive and anaerobic organisms. The risk of infection-erosion was found to be increased in the presence of two main factors, improper urethral catheterization and urethral endoscopic manipulation with an activated AMS 800 artificial sphincter in place and exposure to radiation. At the time of revision, nine of the 13 patients were found to have positive urine cultures. CONCLUSION: Despite all the precautions taken, there remains a group of patients who are still at a higher risk of infection-erosion due to adverse circumstances that distort the anatomy of the perineal area, impair the host defence mechanisms, and ultimately enable the establishment of the infection-erosion complex. Radiotherapy is known to increase the likelihood of non-mechanical complications, specifically infection-erosion. Extreme care must be taken so that avoidable iatrogenic factors such as improper urethral catheterization and endoscopic manipulation with an activated AMS 800 device in situ are not the cause of 'failure'.

Aged↗
PubMed1995

Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens.

PURPOSE: In an attempt to identify women who may be appropriate candidates for orthotopic lower urinary tract reconstruction, archival cystectomy specimens from female patients undergoing cystectomy for primary bladder cancer were reviewed. These pathological findings should provide a better understanding of tumor involvement at the bladder neck (vesicourethral junction) and urethra in women with transitional cell carcinoma of the bladder. MATERIALS AND METHODS: Cystectomy specimens of 67 consecutive women undergoing surgery for biopsy proved transitional cell carcinoma of the bladder between July 1982 and July 1990 were pathologically reviewed. RESULTS: Histological evidence of tumor (carcinoma in situ or gross carcinoma) involving the urethra was present in 9 patients (13%). Tumor was confined to the proximal and mid urethra, and the distal urethra was not involved. All patients with carcinoma involving the urethra had concomitant evidence of carcinoma involving the bladder neck. A total of 17 patients (25%) had tumor involvement of the bladder neck and those with an uninvolved bladder neck also had an uninvolved urethra. The association between the presence of tumor in the bladder neck and urethra was highly significant (p < or = 0.00012). Tumor involving the bladder neck and urethra tended to be more commonly associated with high grade and stage tumors, and node-positive disease. CONCLUSIONS: Although the fate of the retained urethra following cystectomy for bladder cancer in women is unknown, these results show that women with transitional cell carcinoma of the bladder without evidence of tumor involving the bladder neck are at low risk for urethral malignancy. These patients may be offered lower urinary tract reconstruction that includes preservation of and diversion through the urethra (orthotopic diversion). Urethral surveillance will be necessary, as it is in men after orthotopic urinary diversion.

Carcinoma in Situ↗
PubMed1995

Continent and orthotopic urinary diversion following radical cystectomy. Should these reconstructive procedures now be considered standard of care?

Our extensive operative experience with various forms of the continent ileal reservoir in more than 1000 patients over the past 12 years has demonstrated clearly the extreme reliability and durability of this diversion system. Reflux reliably can be prevented and the upper urinary tracts protected. Patients can void or catheterize with confidence. Orthotopic diversions should now be available to most patients, both male and female. Patients should be able to live a more normal life style with a positive self image. We believe that because our modifications of the ileal reservoir systems have decreased the need for reoperation, these forms of continent urinary diversion have emerged as optimal operations and even as the standard of care in cystectomy patients. Ileal conduits should be reserved for poor-risk candidates with short-term life expectancy or for those patients not motivated for continent diversion. The most vocal advocates of the procedures remain those continent diversion patients who have had urinary diversion by another method. Patients still must be aware that complications can occur. Appropriate patient motivation and a thorough understanding of the continent diversion technique and its potential problems continue to be essential prerequisites of the operation. Although minor refinements to these systems will continue to be made, we feel that continent diversion, most often in the form of orthotopic reconstruction, can be offered safely and wisely most to patients.

Cystectomy↗
PubMed1995

Artificial urinary sphincter in patients following major pelvic surgery and/or radiotherapy: are they less favorable candidates?

Between January 1988 and December 1992 the AMS800* artificial urinary sphincter was inserted in 81 men with urinary incontinence due to major pelvic surgery and/or radiation therapy. Radical retropubic prostatectomy had been performed in 38 men, radical retropubic prostatectomy with adjuvant radiation in 28, definitive radiation therapy for prostatic carcinoma in 5, abdominoperineal resection with adjuvant radiation in 1 and radical cystectomy with orthotopic urinary diversion in 8, while 1 suffered major pelvic trauma with urethral rupture. A bulbar urethral cuff was used exclusively, with pressure regulating balloons of 51 to 60 and 61 to 70 cm. water. The interval for primary activation ranged from 4 to 12 weeks (mean 7.7), with all irradiated patients waiting 12 weeks. Surgical revision was required in 38% of the patients totaling 43 operations. Inadequate cuff compression after presumed urethral atrophy secondary to hypovascularity accounted for 74% of the procedures, whereas infection with or without erosion necessitated 8 revisions, mostly attributable to improper placement elsewhere of an indwelling catheter after the artificial urinary sphincter had been activated. Mechanical malfunction was responsible for 7% of the revisions. Overall, socially acceptable continence was achieved in 91% of the study population. Despite a significantly greater need for revision in this high risk group (38% versus 22% in the literature for low risk groups) with meticulous surgical and sterile techniques as well as diligent followup, the long-term outcome in terms of continence and device survival may be excellent regardless of the underlying etiology. We conclude that use of the AMS800 artificial sphincter for significant male urinary incontinence is undoubtedly the most efficacious treatment currently available for which even the most adverse candidate should not necessarily be excluded.

Adult↗
PubMed1994

Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience.

Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.

Adult↗
PubMed1994

Undiversion in men following prior cystoprostatectomy and cutaneous diversion. Is it practical?

This report discusses the feasibility and functional outcome of conversion to an orthotopic Kock neobladder in 11 men (average age 58 years) who underwent cystoprostatectomy and cutaneous urinary diversion an average of 7.3 years previously are discussed. Cystectomy had been performed for bladder cancer in 9 men and for multiple failed bladder reconstructions in 2. No patient had any evidence of recurrent cancer. The reasons for conversion to a Kock neobladder included complications with the current form of diversion (stomal stenosis, leakage and so forth) and dislike of a cutaneous stoma. Average followup since neobladder conversion was 36 months. The exactness of the anastomosis to the urethra and the presence of a retained apex of the prostate were major factors in the technical success of the operation, degree of continence and satisfaction of the patients. All 4 patients who had some portion of retained prostate enjoy excellent continence without anastomotic stricture. In 2 of the early undiversion patients with direct membranous urethral anastomoses anastomotic strictures occurred and they subsequently chose to resume continent cutaneous diversion. The other 5 patients with anastomoses to the membranous urethral stump did well but 2 required an artificial urinary sphincter for continence. These latter 5 patients had more extensive pelvic mobilization of the urethra for more exact anastomoses. The satisfaction level of all 9 continuing neobladder patients, even if an artificial urinary sphincter was necessary, has been exceptional.

Adult↗
PubMed1994

Stenosis of the afferent antireflux valve in the Kock pouch continent urinary diversion: diagnosis and management.

Between August 1982 and May 1988, 503 patients underwent construction of a continent ileal reservoir (Kock pouch) for cutaneous urinary diversion at our university. Stenosis of the afferent antireflux valve resulted in upper urinary tract obstruction in 11 patients (2%). In addition, 2 patients underwent Kock pouch diversion elsewhere and upon referral to our institution they had afferent valve stenosis. To date 13 patients have been identified with this problem. Hydronephrosis was present in 100% of the functional kidneys in these patients. Radiographs of the Kock pouch were uniformly normal without evidence of reflux or other pathological condition. The most common presenting symptom was flank pain in 7 patients (54%) and the most common presenting sign was creatinine elevation above baseline in 7 (54%). Infections recurred with or without sepsis in 5 patients (38%). Ureteroileal anastomotic strictures were not present in any patient. The interval from creation of the Kock pouch to the diagnosis of stenosis ranged from 2 to 75 months (mean 39). All patients underwent endoscopic evaluation of the Kock pouch confirming stenosis of the afferent antireflux valve, and subsequent mechanical dilation of the stenotic valve. Dilation procedures were repeated in 6 patients (46%), 4 of whom subsequently required open surgical revision of the afferent valve. Of these patients 3 are clinically stable and 1 died of the primary malignancy. The remaining 2 patients are clinically and radiographically stable after multiple dilations. Of the 7 patients (54%) requiring only a single dilation 6 are clinically stable and 1 died of the primary malignancy. Stenosis of the afferent antireflux valve of the Kock pouch, previously unreported to our knowledge, is a rare late complication leading to flank pain, hydronephrosis, recurrent infection and elevation of serum creatinine levels. Approximately 50% of the patients respond to a single dilation of the nipple valve. However, most patients who require repeat dilation will need open surgical revision.

Adult↗
PubMed1994

Managing diversity.

The U.S. work force is becoming increasingly diverse as the 20th century approaches. Statistics prove that most organizations are experiencing gender, culture, and age diversity within their labor forces. All managers and leaders must accept this diversity and work to handle it effectively. This article examines the current literature concerning management of diversity and its implications for the health care profession. Gender, culture, and age diversity and the potential problems that may arise with each are also addressed. Reasons to manage diversity are offered, as well as methods of managing diversity for both the manager and the chief executive officer.

Adolescent↗
PubMed1994

Management of benign prostatic hyperplasia.

The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in urology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of these items of progress in urology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Urology of the California Medical Association, and the summaries were prepared under its direction.

Humans↗
PubMed1994

[Reconstruction of the lower urinary tract after cystectomy. Experiences and results in 126 patients with the Kock ileum reservoir in conjunction with bilateral ureteroileourethrostomy].

Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patients acceptance with few late complications or need for reoperation.

Adult↗