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Biomedical subjects

T P Stephenson

Publications and source records attributed to T P Stephenson.

At least 19 recordsLinked to original sources
PubMed1999

An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome.

PURPOSE: We assessed the urodynamic changes after pubovaginal sling procedure for stress incontinence, particularly in regard to the associated symptoms of urgency, frequency, nocturia and urge incontinence, known as the urge syndrome. MATERIALS AND METHODS: A total of 85 women with proved stress incontinence underwent a pubovaginal sling procedure using rectus fascia between 1992 and August 1996. Of the women 41 (48%) had undergone previous anti-incontinence surgery and 59 (69%) had the associated urge syndrome. There was at least some degree of hypermobility in 51 cases and type III stress incontinence was diagnosed in 34. Patients were assessed with a questionnaire and video urodynamics preoperatively and 3 months postoperatively. Preoperative and postoperative ambulatory studies were performed in 25 cases. RESULTS: Of the 85 patients 83 (97%) were symptomatically cured of stress incontinence. The urge syndrome resolved in 32 patients (69%), almost all of whom had a closed bladder neck at rest. Overall bladder neck incompetence at rest decreased from 57 to 18% (p<0.001). Of 27 patients with the persistent urge syndrome postoperatively 9 (41%) had an open bladder neck at rest compared to 4 of 50 (8%) without urge incontinence (p<0.01). Despite symptomatic control of stress incontinence in 83 patients (97%), only 66 were satisfied with the surgical result, mainly because of the persistent urge syndrome in 27. Despite care to avoid obstruction overall, there were statistically significant obstructive changes in detrusor pressure at maximum flow rate, maximum flow rate and residual urine volumes. CONCLUSIONS: The pubovaginal sling is effective in curing genuine stress incontinence and, when correctly placed at the right tension, the associated urge syndrome also can be managed, usually by achieving bladder neck closure at rest. However, despite careful maneuvers, obstruction occasionally persists.

Female↗
PubMed1997

Pentosanpolysulphate for interstitial cystitis.

Interstitial Cystitis (IC) is a chronic disease of unknown etiology which primarily affects women aged 40-60 years. Many plausible theories for the development of IC have been postulated, and one current theory is that these patients have a quantitative and qualitative defect in the glycosaminoglycan (GAG) layer of the urothelium. Such a defect may allow toxic substances in the urine to gain access to the lamina propria and initiate a chronic inflammatory process. Pentosanpolysulphate (PPS) is a sulphated proteoglycan similar in structure to heparin sulphate, which is quantitatively the major GAG on cell surfaces. Exogenously administered PPS has been shown in several studies to decrease bladder pain and urinary frequency and to increase the voided volume. Further studies are required to evaluate the role of PPS in the management of IC patients, with particular emphasis on dosage, route of administration and combination with other compounds.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1997

The fate of the 'modern' artificial urinary sphincter with a follow-up of more than 10 years.

OBJECTIVE: To assess the long-term outcome of patients who had an artificial urinary sphincter (AUS) implanted between 10 and 15 years ago. PATIENTS AND METHODS: Of 68 patients who had an AUS implanted more than 10 years ago, 61 were followed with sufficient detail for analysis. Thirty-four had a neuropathic bladder with sphincter dysfunction, 15 had post-prostatectomy sphincter weakness incontinence and 12 further patients had a variety of indications. RESULTS: The 61 patients experienced a total of 58 major complications and 49 have required at least one revision procedure. Currently eight (13%) patients are satisfactorily continent with their original AUS in situ and 29 others have a satisfactory revised AUS. Thus 37 of 61 (61%) are continent using an AUS at least 10 years after first implantation. Eleven patients died and of these two had a satisfactory original AUS in situ and seven had successful revisions. In two patients the AUS failed but they were considered unfit for revision. Four female patients were continent and used intermittent catheterization after the explantation of eroded AUS cuffs. In seven patients the AUS was abandoned; two of these patients reverted to condom drainage and five had continent or incontinent urinary diversions fashioned. Thus, if those who died with a functioning AUS are included, 46 of 61 (75%) achieved long-term continence with the AUS. CONCLUSIONS: Despite the high complication and revision rate, these results show that acceptable continence rates can be achieved in the long-term, particularly in the male neuropathic bladder and in those with post-prostatectomy sphincter weakness. Many of the complications encountered may be less common with the current re-designed models of the AUS. However, it is essential that both surgeon and patient recognize and accept the likelihood of complications and revisions before using the AUS. The continued use of the AUS where simpler methods of obtaining continence are inappropriate remains justified.

Adolescent↗
PubMed1997

Antioxidant deficiency following clam enterocystoplasty.

OBJECTIVE: To assess whether there is a reduction in serum antioxidant activity in patients who have undergone a clam enterocystoplasty procedure. PATIENTS AND METHODS: Serum glutathione peroxidase (GPase) activity was measured in 20 patients who had undergone clam enterocystoplasty. Serum selenium concentration was also measured in 62 similar patients and compared with 56 healthy controls and 44 patients with a neuropathic bladder, mainly patients with spinal cord injuries who had not undergone surgery. RESULTS: GPase activity correlated well with serum selenium measurement. There was a significant reduction (P < 0.001) in serum selenium level in young (< 50 years old) non-neuropathic bladder patients following clam enterocystoplasty. This reduction in serum selenium was similar to that found in both unoperated patients with a neuropathic bladder (who are known to have an increased risk of developing bladder cancer) and those patients with a neuropathic bladder who had undergone augmentation. This reduction was not related to urinary tract infection nor the time since surgery. CONCLUSION: A reduction in serum selenium has been shown to increase susceptibility to bladder cancer following carcinogenic exposure to compounds such as nitrosamines. This study suggests that patients with idiopathic and congenital instability may be at an equally high risk as a result of undergoing this procedure.

Adolescent↗
PubMed1997

Tumors in bladder remnant after augmentation enterocystoplasty.

PURPOSE: We attempted to determine the tissue of origin of tumors after augmentation enterocystoplasty. MATERIALS AND METHODS: We retrospectively reviewed the histological findings of 4 tumors that developed after clam ileocystoplasty. RESULTS: Tumors were primarily adenocarcinoma that originated on the bladder side of the anastomosis. The urothelium showed glandular metaplasia and dysplasia with intestinalization overlying normal detrusor muscle. These changes were also present in the renal pelvis in 1 patient with ureteral reflux. Bowel mucosa was normal except for inflammation. CONCLUSIONS: These tumors are derived from urothelium, which may be due to elevated urinary nitrosamines in this group of patients.

Adenocarcinoma↗
PubMed1996

Reduction of urinary basic fibroblast growth factor using pentosan polysulphate sodium.

OBJECTIVE: To evaluate the use of pentosan polysulphate sodium (PPS) to reduce the level of urinary basic fibroblast growth factor (bFGF). PATIENTS AND METHODS: Forty-one patients with a clam enterocystoplasty were randomized to receive either 200 mg three times daily of oral PPS (n = 21) or placebo (n = 20) for 6 weeks. Three patients acted as a cross-over study. Urinary bFGF was measured before and after treatment and the degree of symptomatic benefit assessed using a questionnaire. RESULTS: There was no reduction in bFGF in the patients receiving placebo (P = 0.235) but there was a statistically significant reduction in bFGF (P = 0.0251) in the patients receiving PPS, most of whom were symptomatically improved, especially with regard to mucus production. CONCLUSION: PPS may have a role in reducing urinary bFGF in patients with bladder tumours or following an enterocystoplasty and also in improving the quality of life of patients with a clam enterocystoplasty.

Adolescent↗
PubMed1996

Estimation of bladder volume using portable ultrasound in clam enterocystoplasty patients.

PURPOSE: We evaluated portable ultrasound for the measurement of residual volume following clam enterocystoplasty. MATERIALS AND METHODS: Bladder volumes were measured in 25 clam enterocystoplasty patients using a portable ultrasound machine and compared with urethral catheter volumes. A similar study was performed on a control group of 50 patients with normal bladder architecture. RESULTS: There was a close correlation (r = 0.978) between ultrasound and catheter volumes in the control group with a regression line slope of 0.88. There was an equally close correlation (r = 0.960) in the clam enterocystoplasty group but the regression line slope was lower at 0.65, which suggests an underestimation of the true bladder volume. There was a significant difference (p < 0.0001) between the ultrasound-to-catheter volume ratio in the 2 groups. CONCLUSIONS: Portable ultrasound is inaccurate for the measurement of residual bladder volume in clam enterocystoplasty patients.

Case-Control Studies↗
PubMed1996

Elevated levels of basic fibroblast growth factor in the urine of clam enterocystoplasty patients.

PURPOSE: We determined whether basic fibroblast growth factor is elevated in the urine of patients who have undergone clam ileocystoplasty. MATERIALS AND METHODS: An immunoassay technique was used to measure urinary basic fibroblast growth factor in 50 patients equally divided between those with and without neuropathy who had undergone clam enterocystoplasty. The results were compared with urinary basic fibroblast growth factor concentrations from 25 healthy age and sex matched volunteers. RESULTS: There is a highly significant elevation of urinary basic fibroblast growth factor in clam enterocystoplasty patients compared to controls, which is not related to the presence or absence of infection. There is no difference between those with and without neuropathy. CONCLUSIONS: Elevated levels of basic fibroblast growth factor are an important consideration in the malignant potential of the clam procedure.

Adolescent↗
PubMed1995

Comparison of relaxation responses of detrusor strips from neuropathic and control patients.

OBJECTIVES: To confirm the existence of relaxation responses to electrical-field stimulation in strips of human detrusor, and to compare these responses in strips from control subjects with those in strips from a group of neuropathic patients exhibiting hyperreflexia. PATIENTS AND METHODS: Detrusor specimens were obtained at operation from a group of control patients, and from a group of patients with neuropathy (mainly spina bifida) and a history of hyper-reflexia. Muscle strips were prepared from these, mounted in organ baths, and contracted by exposure to a modified Krebs' solution containing 26 mM KCl and atropine. Relaxation responses were induced by an electrical-field stimulation (50 V, 90 microsecond pulses at 2-16 Hz for 10 s). RESULTS: Of 29 strips, 20 (69%) from control patients showed relaxations, compared with 17 of 28 strips (61%) from neuropathic patients (P > 0.1). The maximum relaxation response in the control strips was 49 +/- 5.6% (mean +/- SEM) of the maximum relaxation induced by isobutyl methylxanthine, compared with 43 +/- 4.8% in the strips from neuropathic patients (P > 0.1). The maximum response occurred at similar frequencies (4 or 8 Hz) in the two groups. The relaxations were reduced by the inhibitor of nitric oxide synthase, N-nitro L-arginine methyl ester (0.1 mM, P < 0.05), but were not affected by guanethidine (50 microM) or tetrodotoxin (0.5 microM). CONCLUSION: These results confirm the existence of field stimulation-induced relaxation in human detrusor, but suggest that hyper-reflexia in the neuropathic bladder cannot be accounted for by any deficiency in this response.

1-Methyl-3-isobutylxanthine↗
PubMed1995

Clam enterocystoplasty and pregnancy.

OBJECTIVE: To assess the course and outcome of pregnancy in patients who have undergone clam enterocystoplasty. PATIENTS AND METHODS: A retrospective study was carried out of 19 pregnancies in 18 women aged from 21 to 36 years who had undergone clam enterocystoplasty. RESULTS: Urinary tract infection was common but renal function remained normal with prompt treatment with antibiotics. No other adverse antenatal factors were identified and all pregnancies had a normal fetal outcome. Vaginal delivery was a safer option for these patients, even in those who had undergone an anti-incontinence procedure in addition to enterocystoplasty. CONCLUSION: Careful antenatal monitoring by both an obstetrician and a urologist resulted in a successful pregnancy and vaginal delivery in these patients.

Adult↗
PubMed1995

Bile acid dysfunction after clam enterocystoplasty.

OBJECTIVE: To determine if the bowel dysfunction that develops in approximately 12% of patients after a clam enterocystoplasty is due to disruption of the enterohepatic circulation of bile acids. PATIENTS AND METHODS: Fourteen symptomatic patients (mean age 36 years, range 21-65) who had undergone clam enterocystoplasty were investigated by bowel frequency charts, hydrogen breath tests of expired air and the retention of radioactive 75Se-labelled homocholic acid-taurine (SeHCAT), a synthetic bile acid. Patients with abnormal results were commenced on anion-exchange resins and the symptoms evaluated 6 weeks later. RESULTS: The interruption of bile acid circulation, as estimated by SeHCAT, occurred in most of the patients studied and was due to surgical resection of the terminal ileum. All hydrogen breath tests were normal, excluding bacterial overgrowth as a cause of diarrhoea. Bowel frequency correlated well with the percentage of SeHCAT retained. Anion-exchange resins were successful in relieving the symptoms if patients complied well with the treatment. CONCLUSIONS: After clam enterocystoplasty, some patients have bowel dysfunction caused by the interruption of the enterohepatic circulation of bile acids. These patients can be identified using bowel frequency charts and treated by anion-exchange resins.

Adult↗
PubMed1995

Substitution cystoplasty for intractable interstitial cystitis.

OBJECTIVE: To assess the results of substitution cystoplasty for the treatment of intractable interstitial cystitis (IC). PATIENTS AND METHODS: Thirty-two patients (29 women and three men; mean age 58 years, range 24-74) with intractable IC resistant to conservative therapy who had undergone substitution cystoplasty between 1983 and 1992 were reviewed. Their bladder capacities were measured pre-operatively and related to the outcome of treatment. RESULTS: All but two of the 22 women with a bladder capacity of < 250 mL under anaesthetic were improved (five) or cured (15) of their symptoms. The results in women with larger bladder capacities were much less reliable, with only two of seven being cured of their symptoms. The three men all had a good result. Those who had undergone supratrigonal cystectomy were more likely to void spontaneously, but four patients developed pyelonephritis from associated reflux. Subtotal cystectomy reduced the likelihood of reflux and, although there were too few patients for statistical significance, probably increased the chance of cure at the expense of increasing the need for intermittent self-catheterization (ISC). CONCLUSIONS: Pre-operative bladder capacity under anaesthetic is the most reliable predictor of outcome of substitution cystoplasty for treating intractable IC in women. It is contra-indicated if bladder capacity is > 250 mL. Supratrigonal cystectomy is a quick and easy operation and is preferable in the older patient. Subtotal cystectomy with reimplantation of the ureters is preferable in the younger patient, even though it may increase the need for ISC.

Adult↗
PubMed1995

Physiological and morphometric studies into the pathophysiology of detrusor hyperreflexia in neuropathic patients.

The in vitro responses of isolated detrusor strips obtained from neuropathic patients with neuropathic bladder dysfunction were found to be supersensitive to both carbachol [ED50 1.2 x 10(-6) M. versus 2.5 x 10(-6) M. in control strips; p < 0.005] and potassium chloride [ED50 41.8 mM. versus 49.3 mM. in control strips, p < 0.05]. There were no significant differences in the frequency-response curves obtained with intramural nerve stimulation. However, expressed as a percentage of the maximal response with carbachol, the maximal responses to intramural nerve stimulation in neuropathic strips were reduced [58.3 +/- 21% versus 74.4 +/- 18% for control strips; p < 0.005, Student t test]. Morphometric studies revealed a lower density of 'presumptive' cholinergic nerves in neuropathic detrusor (1.0 +/- 1.4 x 10(-4) microns -2 compared with 3.2 +/- 1.3 x 10(-4) microns -2 in controls, p < 0.05, Mann Whitney U test). The combined physiological and morphometric results were in keeping with a state of postjunctional supersensitivity of neuropathic detrusor secondary to a partial parasympathetic denervation of the smooth muscle. This may be an important factor in the etiology of detrusor hyperreflexia. The contractility of neuropathic tissue in response to field stimulation was found to be much lower than normal (2.4 +/- 1.5 g./10 mg. versus 5.9 +/- 3.0 g./10 mg., p < 0.001; Mann Whitney U test). This reduced contractility to neuronal stimulation might be responsible for some of the characteristics of bladder dysfunction that are seen in patients with similar neurological conditions.

Adult↗
PubMed1994

Transplanting patients with abnormal lower urinary tracts.

Since 1977, 23 patients with bladder or bladder outlet dysfunction leading to renal failure have received 28 kidney transplants in our institution. Three patients were provided with an ileal conduit, but the remainder were transplanted using their own bladder following urodynamic assessment and bladder reconstruction. Graft and patient survival were good when compared to a group of patients with normal lower urinary tracts, actuarial graft survival at 5 years being 70% for both groups and patient survival being 82% and 90%, respectively. Patients who develop renal failure from detrusor/sphincter dysfunction can be transplanted successfully once the cause of the renal failure has been identified and corrected.

Adolescent↗
PubMed1994

An assessment of the contribution of visco-elastic factors in the aetiology of poor compliance in the human neuropathic bladder.

OBJECTIVE: To compare the mechanical properties of fullthickness bladder strips from poorly compliant neuropathic bladders with controls and to determine the overall contribution that mechanical factors might have in the aetiology of the poor compliance of medium-fill cystometry. PATIENTS AND METHODS: The visco-elastic properties of full-thickness bladder strips from 11 neuropathic patients (with poorly compliant bladders during medium-fill cystometry) were compared with strips from 11 control bladders. A strip (measuring 2 cm long and 0.5 cm wide) was mounted in an organ bath and stretched by 1 cm at a slow and at a fast rate. The stretches were repeated in modified Krebs solution containing zero calcium and 12 mM magnesium. The final experiment involved stretching the strip by 1 cm in < 1 s (instantaneous stretch). RESULTS: Only modest differences in the peak tensions of both tissues were uncovered by the slow and fast stretches (fast stretch: 14.6 +/- 5.5 in neuropaths vs 10.1 +/- 4.1 g in controls, P = NS; slow stretch: 9.6 +/- 3.5 in neuropaths vs 6.7 +/- 2.5 g in controls, P < 0.05). Stretches carried out in modified Krebs solution resulted in lower tensions. Fast, intermediate and slow components of viscous decay (derived from the rate of tension decay following the instantaneous stretch) were not significantly different in neuropaths compared to controls (P = NS). CONCLUSION: The differences in the mechanical properties between neuropathic and control bladder strips were small and could not alone have accounted for the large differences in bladder compliance that was observed between neuropathic and normal patients during medium-fill cystometry. This implied that neurogenic rather than mechanical factors were more important in the aetiology of the observed poor compliance in these patients.

Adolescent↗