Current and future international patterns of care of neurogenic bladder after spinal cord injury.

PURPOSE: We aim to summarize the literature on international patterns of care for patients with neurogenic bladder (NGB) from spinal cord injury (SCI). METHODS: We performed a PubMed database search, hand review of references, communication with professional societies, and registry evaluations for pertinent data. RESULTS: Established patterns of care, including SCI registries and specialty centers, are available in high-resource countries such as the US and UK. As such, mortality rates from complications of NGB/SCI are lower. Access to intermittent catheterization supplies, among other resources, may be inadequate in many low-income regions. Cultural and religious beliefs may also hinder integration of proper bladder management in SCI patients. While guidelines exist in many parts of the world, it is unclear how rigorously they are disseminated or followed. CONCLUSIONS: While there is a paucity of high-level evidence, the differences in patterns of care are closely related to socioeconomic status and resources of the geographic area. Future research efforts should focus on improving access to diagnostic modalities, supplies, and specialists in these areas.

Urinary incontinence in women: non-pharmacologic approaches and newer pharmacotherapies.

Stress urinary incontinence (SUI) is a common and bothersome problem for women. Sling surgery is the mainstay of surgical treatment of SUI. A review of PubMed literature using the following keywords was performed: stress urinary incontinence, women, sling, midurethral sling, mini-sling, outcomes, and complications. Literature within the last 10 years, systematic reviews, and meta-analyses were given preference. Slings placed at the bladder neck and the midurethra each corrects a particular anatomic weakness, as described in the "hammock hypothesis" and the "integral theory," respectively. At present, the literature suggests that the autologous bladder neck sling (BNS) and retropubic midurethral sling (MUS) have similar success rates, while the retropubic MUS appears to be more successful than the transobturator approach. The literature supporting single-incision mini-sling (SIMS) is still in the early stages and data to support its use over another MUS is absent. Each approach is associated with unique complications and adverse outcomes. While both BNS and MUS are effective in improving SUI in women, the ultimate choice of material and approach should be based both on surgeon experience and patient preference. Detailed informed consent discussion prior to any sling surgery cannot be overemphasized.

Fesoterodine fumarate.

Overactive bladder (OAB) is a common condition that causes a profound impact on an individual's overall health and quality of life. Muscarinic antagonists are the mainstay of oral pharmacotherapy for OAB. The most-recently introduced muscarinic antagonist, fesoterodine fumarate, is unique in that the parent compound has no antimuscarinic efficacy due to its rapid and complete hydrolysis after oral administration. The active metabolite, 5-hydroxymethyl tolterodine, is responsible for all of the antimuscarinic effects. In two phase III studies, fesoterodine has been shown to significantly reduce mean urgency and urge urinary incontinence (UUI) episodes over placebo. As many as 60% of patients actively treated with fesoterodine reported no urge urinary incontinence episodes on a 3-day voiding diary, a significant improvement over placebo. Finally, several quality of life indices were significantly improved over placebo. There was a dose-related increase in antimuscarinic adverse events, such as dry mouth and constipation; however, few patients discontinued fesoterodine due to side effects.

Management of grade IV renal injury in children.

PURPOSE: Conservative nonsurgical management of major renal trauma in children is well established. However, when blunt trauma is accompanied by significant urinary extravasation, options are less than clearly defined. Endoscopic techniques, such as stents and percutaneous drainage, have not been widely used because of small caliber. We present our experience with endoscopic management of grade IV renal trauma. MATERIALS AND METHODS: From 1983 to 1996, 15 children satisfied the criteria for grade IV renal trauma. We retrospectively reviewed the charts to assess the mechanism of injury, associated injury, treatment, hospital stay and transfusion requirement. Patients were followed clinically with blood pressure and creatinine monitoring, and by radiograph with computerized tomography. RESULTS: Nine patients with isolated kidney injury were successfully treated with observation, 1 underwent early partial nephrectomy for persistent anemia and hypotension, and 5 had a urinoma, which was successfully treated with percutaneous drainage only in 2. The other 3 patients underwent cystoscopy and ureteral stent placement for high drainage output, leading to the resolution of urine leakage. In 1 patient who underwent percutaneous drainage only renovascular hypertension developed, requiring partial nephrectomy 3 months after the original injury. The remaining 13 patients had complete radiographic resolution of the injury and no evidence of hypertension. CONCLUSIONS: In the pediatric population grade IV blunt renal trauma usually resolves without intervention. When a symptomatic urinoma develops, percutaneous drainage, accompanied at times by ureteral stenting provides the complete resolution of persistent urine leakage.

Predictors of developmental outcomes in children with complete transposition.

Cognitive, functional, educational achievement and behavioural measures were employed to assess neurobehavioral status in 57 of 60 participants who were initially enrolled in the Baltimore-Washington Infant Study, and who survived surgical correction of complete transposition (concordant atrioventricular and discordant ventriculo-arterial connections). Charts were reviewed to investigate the relationship between birth variables, surgical strategy and developmental outcomes. Higher preoperative weight was associated with better outcomes on the Stanford-Binet Short-term Memory subtest, while lower preoperative oxygen tension was associated with better outcomes on the Abstract/Visual Reasoning subtest and a test of Visual-Motor Integration. Longer total bypass time was associated with poor outcomes on the Short-term Memory subtests. Higher average flow rates during cooling and rewarming were associated with higher scores in the test of short term memory but poorer outcomes on a test for visual motor integration. Longer cooling times were associated with higher scores on the test for Visual-Motor Integration. Patients suffering seizures scored lower on the Stanford-Binet Composite, as well as in their tests of achievement. The data indicate that non-verbal skills may be particularly sensitive to variations in surgical strategies employed to correct complete transposition. Overt neurological events, such as seizures, were related to global deficits in intellectual functioning. Prospective studies evaluating systemic variations in surgical procedures and attempts to prevent and manage perioperative neurological events are important for further investigation of neurodevelopmental outcomes in children surviving surgical correction.

Spontaneous mediastinal hemorrhage: a case report with a review of the literature.

A patient on chronic hemodialysis presenting with shortness of breath and dysphagia was found to have massive hemomediastinum. A review of the world's literature prompted by this case reveals that this rare entity can be classified into three general groups: (1) hemomediastinum secondary to underlying bleeding disorder, (2) hemomediastinum secondary to hemorrhage into a mediastinal organ or gland, without underlying bleeding disorder and (3) idiopathic hemomediastinum, without underlying bleeding disorder. Therapy depends upon the underlying etiology and the severity of symptoms.