Intermediate-term survival of robot-assisted versus open radical cystectomy for muscle-invasive and high-risk non-muscle invasive bladder cancer in The Netherlands.

BACKGROUND: Radical cystectomy with pelvic lymph node dissection is the recommended treatment in non-metastatic muscle-invasive bladder cancer (MIBC). In randomised trials, robot-assisted radical cystectomy (RARC) showed non-inferior short-term oncological outcomes compared with open radical cystectomy (ORC). Data on intermediate and long-term oncological outcomes of RARC are limited. OBJECTIVE: To assess the intermediate-term overall survival (OS) and recurrence-free survival (RFS) of patients with MIBC and high-risk non-MIBC (NMIBC) who underwent ORC versus RARC in clinical practice. METHODS AND MATERIALS: A nationwide retrospective study in 19 Dutch hospitals including patients with MIBC and high-risk NMIBC treated by ORC (n = 1086) or RARC (n = 386) between January 1, 2012 and December 31, 2015. Primary and secondary outcome measures were median OS and RFS, respectively. Survival outcomes were estimated using Kaplan-Meier curves. A multivariable Cox regression model was developed to adjust for possible confounders and to assess prognostic factors for survival including clinical variables, clinical and pathological disease stage, neoadjuvant therapy and surgical margin status. RESULTS: The median follow-up was 5.1 years (95% confidence interval ([95%CI] 5.0-5.2). The median OS after ORC was 5.0 years (95%CI 4.3-5.6) versus 5.8 years after RARC (95%CI 5.1-6.5). The median RFS was 3.8 years (95%CI 3.1-4.5) after ORC versus 5.0 years after RARC (95%CI 3.9-6.0). After multivariable adjustment, the hazard ratio for OS was 1.00 (95%CI 0.84-1.20) and for RFS 1.08 (95%CI 0.91-1.27) of ORC versus RARC. Patients who underwent ORC were older, had higher preoperative serum creatinine levels and more advanced clinical and pathological disease stage. CONCLUSION: ORC and RARC resulted in similar intermediate-term OS and RFS in a cohort of almost 1500 MIBC and high-risk NMIBC.

Training novice robot surgeons: Proctoring provides same results as simulator-generated guidance.

To understand the influence of proctored guidance versus simulator generated guidance (SGG) on the acquisition dexterity skills in novice surgeons learning RAS (robot assisted surgery). Prospective non-blinded 3-arm randomised controlled trial (RTC). Exclusion criteria: previous experience in RAS or robotic surgery simulation. The participants were assigned to three different intervention groups and received a different form of guidance: (1) proctored guidance, (2) simulator generated guidance, (3) no guidance, during training on virtual reality (VR) simulator. All participants were asked to complete multiple questionnaires. The training was the same in all groups with the exception of the intervention part. Catharina Hospital Eindhoven, The Netherlands. A total of 70 Dutch medical students, PhD-students, and surgical residents were included in the study. The participants were randomly assigned to one of the three groups. Overall, all the participants showed a significant improvement in their dexterity skills after the training. There was no significant difference in the improvement of surgical skills between the three different intervention groups. The proctored guidance group reported a higher participant satisfaction compared to the simulator-generated guidance group, which could indicate a higher motivation to continue the training. This study showed that novice surgeons. Significantly increase their dexterity skills in RAS after a short time of practicing on simulator. The lack of difference in results between the intervention groups could indicate there is a limited impact of "human proctoring" on dexterity skills during surgical simulation training. Since there is no difference between the intervention groups the exposure alone of novice surgeons to the robotic surgery simulator could possibly be sufficient to achieve a significant improvement of dexterity skills during the initial steps of RAS learning.

Structured robot-assisted surgery training curriculum for residents in Urology and impact on future surgical activity.

To gain insight into the availability of training for robot assisted surgery (RAS) and the possibility to perform RAS during Dutch residency curriculum and to analyze the effects on surgical skills by the introduction of an advanced course in RAS for residents. A combination of a validated snap shot survey and a prospective cohort study. Structured advanced RAS training including virtual reality (VR) simulation, dry and wet lab facility at ORSI academy (Belgium). A snap-shot survey has been sent to all the residents and specialists in Urology graduated during the years 2017-2020 in Netherlands. Among residents, only last year residents (5th and 6th year) have been considered for the RAS training. Although most of the residents (88.2%) and young urologists (95%) were asked to follow a basic training or meet basic requirements before starting RAS, the requirements set by the educators were different from center to center. Some of them were required to attend only an online course on RAS, whereas others were asked to achieve threshold scores at VR simulator and participate in a standardized course at a training institute. The attendance to a structured advanced course in RAS showed a significant increase in surgical skills. Our study shows residents in urology are allowed to perform RAS during their residency though the criteria for starting RAS differ significantly amongst the teaching hospitals. To guarantee a basic level of skills and knowledge a structured, (multi-step) training and certification program for RAS should be implemented.

Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit.

INTRODUCTION: Surgery for locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) may require total pelvic exenteration with the need for urinary diversion. The aim of this study was to describe outcomes for ileal and colon conduits after surgery for LARC and LRRC. METHODS: All consecutive patients from two tertiary referral centers who underwent total pelvic exenteration for LARC or LRRC between 2000 and 2018 with cystectomy and urinary reconstruction using an ileal or colon conduit were retrospectively analyzed. Short- (≤30 days) and long-term (>30 days) complications were described for an ileal and colon conduit. RESULTS: 259 patients with LARC (n = 131) and LRRC (n = 128) were included, of whom 214 patients received an ileal conduit and 45 patients a colon conduit. Anastomotic leakage of the ileo-ileal anastomosis occurred in 9 patients (4%) after performing an ileal conduit. Ileal conduit was associated with a higher rate of postoperative ileus (21% vs 7%, p = 0.024), but a lower proportion of wound infections than a colon conduit (14% vs 31%, p = 0.006). The latter did not remain significant in multivariate analysis. No difference was observed in the rate of uretero-enteric anastomotic leakage, urological complications, mortality rates, major complications (Clavien-Dindo≥3), or hospital stay between both groups. CONCLUSION: Performing a colon conduit in patients undergoing total pelvic exenteration for LARC or LRRC avoids the risks of ileo-ileal anastomotic leakage and may reduce the risk of a post-operative ileus. Besides, there are no other differences in outcome for ileal and colon conduits.

Psoas hitch ureteral reimplantation after surgery for locally advanced and locally recurrent colorectal cancer: Complications and oncological outcome.

INTRODUCTION: The most important prognostic factor for oncological outcome of rectal cancer is radical surgical resection. In patients with locally advanced T4 rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) (partial) resection of the urinary tract is frequently required to achieve radical resection. The psoas bladder hitch (PBH) technique is the first choice for reconstruction of the ureter after partial resection and this bladder-preserving technique should not influence the oncological outcome. METHODS: Demographic and clinical data were collected prospectively for all patients operated on for LARC or LRRC between 1996 and 2014 who also underwent a psoas hitch ureter reconstruction. Urological complications and oncological outcome were assessed. RESULTS: The sample comprised 70 patients, 30 with LARC and 40 with LRRC. The mean age was 62 years (range: 39-86). Postoperative complications occurred in 38.6% of patients, the most frequent were urinary leakage (22.9%), ureteral stricture with hydronephrosis (8.6%) and urosepsis (4.3%). Surgical re-intervention was required in 4 cases (5.7%), resulting in permanent loss of bladder function and construction of a ureter-ileo-cutaneostomy in 3 cases (4.3%). Oncological outcome was not influenced by postoperative complications. CONCLUSION: The rate of complications associated with the PBH procedure was higher in our sample than in previous samples with benign conditions, but most complications were temporary and did not require surgical intervention. We conclude that the bladder-sparing PBH technique of ureter reconstruction is feasible in locally advanced and recurrent rectal cancer with invasion of the urinary tract after pelvic radiotherapy.

High level of patient satisfaction and comfort during diagnostic urological procedures performed by urologists and residents.

OBJECTIVE: The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences. METHODS: Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologists n = 39, residents n = 45) and 138 urethrocystoscopies (UCS; urologists n = 44, residents n = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0-10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors. RESULTS: Median values for patient experiences across procedures were 10 (range 5-10) for patient satisfaction, 2 (0-9) for pain and 8 (0-10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients. CONCLUSIONS: Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position.

Urine flow cytometry can rule out urinary tract infection, but cannot identify bacterial morphologies correctly.

The diagnosis of urinary tract infection (UTI) by urine culture is a time-consuming and costly procedure. Usage of a screening method, to identify negative samples, would therefore affect time-to-diagnosis and laboratory cost positively. Urine flow cytometers are able to identify particles in urine. Together with the introduction of a cut-off value, which determines if a urine sample is subsequently cultured or not, the number of cultures can be reduced, while maintaining a low level of false negatives and a high negative predictive value. Recently, Sysmex developed additional software for their urine flow cytometers. Besides measuring the number of bacteria present in urine, information is given on bacterial morphology, which may guide the physician in the choice of antibiotic. In this study, we evaluated this software update. The UF1000i classifies bacteria into two categories: 'rods' and 'cocci/mixed'. Compared to the actual morphology of the bacterial pathogen found, the 'rods' category scores reasonably well with 91% chance of classifying rod-shaped bacteria correctly. The 'cocci/mixed' category underperforms, with only 29% of spherical-shaped bacteria (cocci) classified as such. In its current version, the bacterial morphology software does not classify bacteria, according to their morphology, well enough to be of clinical use in this study population.

Training robotic surgery in urology: experience and opinions of robot urologists.

BACKGROUND: To answer the research questions: (a) what were the training pathways followed by the first generation of robot urologists; and (b) what are their opinions on the ideal training for the future generation? METHODS: Data were gathered with a questionnaire and semi-structured interviews in a mixed-method research design. RESULTS: The results show that training approaches differed from hardly any formal training to complete self-initiated training programmes, with all available learning resources. The median number of supervised procedures at the start of robot-assisted laparoscopy was five (range 0-100). Before patient-related console time, respondents indicated that the minimum training of robot trainees should consist of: live observations (94% indicated this as essential), video observations (90%), knowledge (88%), table assisting (87%) and basic skills (70%). CONCLUSION: The first generation of robot urologists used different training approaches to start robotic surgery. There is a need for a structured and compulsory training programme for robotic surgery. Copyright © 2014 John Wiley & Sons, Ltd.

Urine flow cytometry as a primary screening method to exclude urinary tract infections.

PURPOSE: To exclude urinary tract infections, culture is the gold standard method, although it is time consuming and costly. Current strategies using dipstick analysis are unsatisfactory as screening methods, because of inadequate sensitivity/specificity. Urine flow cytometry is an attractive alternative. To exclude urinary tract infections, a cutoff value to screen for negative cultures was determined. METHODS: 281 outpatients (51 % male) of a general population visiting the urology department were included. Urine samples were measured by flow cytometry and compared with culture results and dipstick analysis. ROC analysis was performed to evaluate the screening performance of flow cytometry and dipstick analysis compared to culture. RESULTS: 18 % of cultures were positive, defined as >10(4) colony forming units/mL. Bacterial count by flow cytometry alone provides the best sensitivity and specificity to exclude a urinary tract infection. A cutoff value of 60 bacteria/µL urine leads to a sensitivity of 100 % and a specificity of 60 %. Retrospectively, with a cutoff value of 60 bacteria/µL urine, 49 % of the cultures would have been redundant. 20 % of patients receiving antibiotics possibly had received those unnecessarily. The calculated percentage of false negatives was 0 % (95 % confidence interval 0-3.3 %). CONCLUSIONS: Urine flow cytometry is a reliable screening method to exclude urinary tract infections. With a cutoff value of 60 bacteria/µL urine, negative predictive value is 100 % and the calculated percentage of false negatives is 0 % (95 % confidence interval 0-3.3 %). Using flow cytometry as a screening method could lead to a reduction in cultures and antibiotics.

[Silodosin therapy for lower urinary tract symptoms in men with suspected benign prostatic hyperplasia: results of an international, randomized, double-blind, placebo- and active-controlled clinical trial performed in Europe].

BACKGROUND: Silodosin is a new selective therapy with a high pharmacologic selectivity for the a (1A)-adrenoreceptor. OBJECTIVE: Our aim was to test silodosin's superiority to placebo and noninferiority to tamsulosin and discuss the findings in the context of a comprehensive literature review of the new compound silodosin. DESIGN, SETTING, AND PARTICIPANTS: We conducted a multicenter double-blind, placebo-and active-controlled parallel group study. A total of 1228 men > or = 50 yr of age with an International Prostate Symptom Score (IPSS) < or = 13 and a urine maximum flow rate (Q(max))> 4 and < or = 15 ml/s were selected at 72 sites in 11 European countries. The patients were entered into a 2-wk wash-out and a 4-wk placebo run-in period. A total of 955 patients were randomized (2:2:1) to silodosin 8 mg (n = 381), tamsulosin 0.4 mg (n = 384), or placebo (n = 190) once daily for 12 wk. MEASUREMENTS: We calculated the change from baseline in IPSS total score (primary), storage and voiding subscores, quality of life (QoL) due to urinary symptoms, and Q(max). Responders were defined on the basis of IPSS and Q(max) by a decrease of > or = 25% and an increase of > or = 30% from baseline, respectively. RESULTS AND LIMITATIONS: The change from baseline in the IPSS total score with silodosin and tamsulosin was significantly superior to that with placebo (p < 0.001): difference active placebo of -2.3 (95% confidence interval [CI], -3.2, -1.4) with silodosin and -2.0 (95% CI, -2.9, -1.1) with tamsulosin. Responder rates according to total IPSS were significantly higher (p < 0.001) with silodosin (66.8%) and tamsulosin (65.4%) than with placebo (50.8%). Active treatments were also superior to placebo in the IPSS storage and voiding subscore analyses, as well as in QoL due to urinary symptoms. Of note, only silodosin significantly reduced nocturia versus placebo (the change from baseline was -0.9, -0.8, and -0.7 for silodosin, tamsulosin, and placebo, respectively; p = 0.013 for silodosin vs placebo). An increase in Q(max) was observed in all groups. The adjusted mean change from baseline to end point was 3.77 ml/s for silodosin, 3.53 ml/s for tamsulosin, and 2.93 ml/s for placebo, but the change for silodosin and tamsulosin was not statistically significant versus placebo because of a particularly high placebo response (silodosin vs placebo: p = 0.089; tamsulosin vs placebo: p = 0.221). At end point, the percentage of responders by Q(max) was 46.6%, 46.5%, and 40.5% in the silodosin, tamsulosin, and placebo treatment groups, respectively. This difference was not statistically significant (p = 0.155 silodosin vs placebo and p = 0.141 tamsulosin vs placebo). Active treatments were well tolerated, and discontinuation rates due to adverse events were low in all groups (2.1%, 1.0%, and 1.6% with silodosin, tamsulosin, and placebo, respectively). The most frequent adverse event with silodosin was a reduced or absent ejaculation during orgasm (14%), a reversible effect as a consequence of the potent and selective a(1A)-adrenoreceptor antagonism of the drug. The incidence was higher than that observed with tamsulosin (2%); however, only 1.3% of silodosin-treated patients discontinued treatment due to this adverse event. CONCLUSIONS: Silodosin is an effective and well-tolerated treatment for the relief of both voiding and storage symptoms in patients with lower urinary tract symptoms suggestive of bladder outlet obstruction thought to be associated with benign prostatic hyperplasia. Its overall efficacy is not inferior to tamsulosin. Only silodosin showed a significant effect on nocturia over placebo.

A population-based study on the utilisation rate of primary radiotherapy for prostate cancer in 4 regions in the Netherlands, 1997-2008.

AIM: The purpose was to study variations in utilisation rates of external beam radiotherapy (EBRT) and brachytherapy (BT) for prostate cancer patients. MATERIALS AND METHODS: We calculated the proportion and number of EBRT and BT given or planned within 6 months of diagnosis in 4 Dutch regions, according to stage and age in a population-based setting including 47,259 prostate cancer patients diagnosed from 1997 until 2008. RESULTS: During this study period, the overall utilisation rate of EBRT remained stable at around 25%, while the rate of BT for non-metastasized patients increased from 1% (95% CI:0-1%) to 12% (11-13%) in 2006 and slightly decreased towards 10% (9-11%) in 2008. From 2001 on, the overall utilisation rate of EBRT decreased significantly in one region (p<0.05). In this region, a sharp rise in the utilisation rate of BT for non-metastatic patients was noted to 17% (14-20%) in 2008 after a peak of 24% (21-27%) in 2006. For localised disease, BT was used more often at the expense of EBRT while for locally advanced disease the utilisation rate of EBRT increased. In the multivariate analysis, regional differences in the utilisation rate of EBRT persisted with odds ratios ranging from 0.7 to 0.9 compared to the reference region. Moreover, low rates of EBRT were associated with high BT rates. The regional differences could not be explained by differences in risk profiles. CONCLUSIONS: The utilisation rate of EBRT remained stable with limited variation between regions while BT was used increasingly with clear regional differences. To cope with this and in view of the increasing incidence of prostate cancer, adequate resources have to be planned for the optimal care of these patients.

Better survival in patients with metastasised kidney cancer after nephrectomy: a population-based study in the Netherlands.

AIM: Cytoreductive nephrectomy is considered beneficial in patients with metastasised kidney cancer but only a minority of these patients undergo cytoreductive surgery. Factors associated with nephrectomy and the independent effect of nephrectomy on survival were evaluated in this study. METHODS: Patients were selected from the population-based cancer registry and detailed data were retrieved from clinical files. Factors associated with nephrectomy were evaluated by logistic regression analyses. Cox proportional hazard regression analysis was performed to evaluate factors associated with survival; a propensity score reflecting the probability of being treated surgically was included in order to adjust for confounding by indication. RESULTS: 37.5% of 328 patients diagnosed with metastatic kidney cancer between 1999 and 2005 underwent nephrectomy. Patients with a low performance score, high age, ≥2 comorbid conditions, ≥2 metastases, low or high BMI, weight loss, elevated lactate dehydrogenase, elevated alkaline phosphatase, female gender and liver or bone metastases were less likely to be treated surgically. Three year survival was 25% and 4% for patients with and without nephrectomy, respectively (p<0.001). After adjustment for other prognostic factors including the propensity score, nephrectomy remained significantly associated with better survival (Hazard ratio: 0.52, 95% Confidence interval: 0.37-0.73). CONCLUSIONS: Even after accounting for prognostic profile, patients still benefit from a nephrectomy; an approximately 50% reduction in mortality was observed. It is, therefore, recommended that patients with metastasised disease receive cytoreductive surgery when there is no contraindication. Trial results on cytoreductive surgery combined with targeted molecular therapeutics are awaited for.

Scrotal cancer: incidence, survival and second primary tumours in the Netherlands since 1989.

BACKGROUND: Since the 1970s there have been few epidemiological studies of scrotal cancer. We report on the descriptive epidemiology of scrotal cancer in the Netherlands. METHODS: Data on all scrotal cancer patients were obtained from the Netherlands Cancer Registry (NCR) in the period 1989-2006 and age-standardised incidence rates were calculated also according to histology and stage. Relative survival was calculated and multiple primary tumours were studied. RESULTS: The overall incidence rate varied around 1.5 per 1,000,000 person-years, most frequently being squamous cell carcinoma (27%), basal cell carcinoma (19%) and Bowen's disease (15%). Overall 5-year relative survival was 82%, being 77% and 95% for patients with squamous and basal cell carcinoma, respectively. In all, 18% of the patients were diagnosed with a second primary tumour. CONCLUSION: The incidence rate of scrotal cancer did not decrease, although this was expected; affected patients might benefit from regular checkups for possible new cancers.

Testicular cancer: trends in mortality are well explained by changes in treatment and survival in the southern Netherlands since 1970.

The aim of this study was to interpret changes in mortality from testicular cancer (TC) against the background of changes in treatment and survival in the south of The Netherlands. Five-year moving average standardised mortality rates were calculated. Primary treatment and relative survival were analysed according to histology, stage and year of diagnosis. The mortality rate dropped in the period 1979-1986 and then flattened out. The types of treatment that patients received did not change significantly over time and were according to the guidelines. Ten-year relative survival for seminoma TC patients improved from 81% (67-91%) in 1970-1979 to 95% (88-100%) in 2000-2002; for non-seminoma TC patients these rates were 54% (38-68%) and 92% (85-99%), respectively. Conditional 5-year relative survival for seminoma and non-seminoma TC patients 5 years after diagnosis was 99% and 96%, respectively. In conclusion, there was an enormous increase in relative survival and a significant decrease in mortality.

Sacral neuromodulation and pregnancy.

PURPOSE: Sacral neuromodulation is effective for lower urinary tract dysfunction. However, despite its increasing use and a preponderance of female patients treated to our knowledge its effect in pregnant women and developing fetuses remains unknown. Therefore, we obtained information on patients on sacral neuromodulation who then achieved pregnancy. MATERIALS AND METHODS: Data were obtained using a standard questionnaire from 4 physicians with a total of 6 eligible patients. We recorded patient urological history, indication for neuromodulation, pregnancy course, the mode of delivery and neonatal health. We also noted the timing of implant deactivation and reactivation. RESULTS: In 5 patients the stimulator was deactivated between weeks 3 and 9 of gestation, after which 2 with a history of urinary retention had urinary tract infection. In another case, stimulation was discontinued 2 weeks before conception. The only noted complication developed in a pregnancy in which birth was premature at 34 weeks. Three patients underwent normal vaginal delivery, including 1 in whom subsequent implant reactivation did not resolve voiding dysfunction. In 3 cases elective cesarean section was performed. All neonates were healthy. CONCLUSIONS: When a patient on neuromodulation achieves pregnancy, the stimulation should be deactivated. If implant deactivation leads to urinary related complications that threaten the pregnancy, reactivation should be considered. Elective cesarean section should be discussed since it is possible for sacral lead damage or displacement to occur during vaginal delivery.

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. Part I: Clinical and urodynamic analysis. Dutch Study Group on Sacral Anterior Root Stimulation.

OBJECTIVES: To present the clinical and urodynamic results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral rhizotomies and electrical bladder stimulation with the Finetech-Brindley stimulator during a 3-year inclusion and study period. METHODS: 226 patients with spinal cord lesion and urological problems due to hyperreflexia of the bladder were screened for sacral rhizotomies and electrical bladder stimulation. In 52 patients complete posterior sacral root rhizotomies were performed and a Finetech-Brindley sacral anterior root stimulator implanted. All patients were screened and followed with a standard protocol. RESULTS: Complete continence during daytime was achieved in 73% of patients with 6-month follow-up and in 86% at night. Significant increase in bladder capacity and bladder compliance was achieved in all patients. Residual urine was reduced significantly, resulting in a decrease of the incidence of urinary tract infections. CONCLUSIONS: The treatment of neurogenic bladder dysfunction in spinal cord injury by anterior sacral root stimulation with the Finetech-Brindley stimulator in combination with sacral posterior root rhizotomy produces excellent results with limited morbidity.

Results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation.

PURPOSE: We evaluated the results of treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation using the Finetech-Brindley stimulator. MATERIALS AND METHODS: In 52 patients with spinal cord lesions and urological problems due to hyperreflexia of the bladder complete posterior sacral root rhizotomy was performed and a Finetech-Brindley sacral anterior root stimulator was implanted. All patients were evaluated and followed with a strict protocol. A minimal 6-month followup is available in 47 cases. RESULTS: Complete continence was achieved in 43 of the 47 patients with 6 months of followup. A significant increase in bladder capacity was attained in all patients. Residual urine significantly decreased, resulting in a decreased incidence of urinary tract infections. In 2 patients upper tract dilatation resolved. In 3 patients rhizotomy was incomplete and higher sectioning of the roots was necessary. One implant had to be removed because of infection. CONCLUSIONS: The treatment of neurogenic bladder dysfunction in spinal cord injury by anterior sacral root stimulation with the Finetech-Brindley stimulator in combination with sacral posterior root rhizotomy provides excellent results with limited morbidity.

Morphometric data of canine sacral nerve roots with reference to electrical sacral root stimulation.

Experiments to investigate restoration of lower urinary tract control by electrical stimulation of the sacral nerve roots are mostly performed on dogs, yet little morphometric data (such as canine root and fiber diameter distributions) are available. The aim of this study was to acquire morphometric data of the intradural canine sacral dorsal and ventral roots (S1-S3). Cross-sections of sacral roots of two beagle dogs were analyzed using a light microscope and image processing software. The cross-sectional area of each root was measured. The diameters of the fibers and the axons in the cross-sections of the S2 and S3 roots were measured and used to construct nerve fiber diameter frequency distribution histograms. The results show a unimodal diameter distribution for the dorsal roots and a bimodal distribution for the ventral roots. In addition the average ratio g of the axon diameter to fiber diameter was calculated for each root.

Relationship between lower urinary tract abnormalities and disease-related parameters in multiple sclerosis.

Multiple sclerosis affects the lower urinary tract in many patients. The relationship between lower urinary tract abnormalities and disease-related parameters of multiple sclerosis is not well described. We screened urologically and neurologically 212 patients according to a standard protocol. Micturition complaints were noted in 52% of the patients and urodynamic abnormalities were found in 64%. A statistical correlation was found between detrusor hyperactivity and detrusor hypoactivity with disease-related parameters, that is disease duration, disability status, myelin basic protein concentration in the cerebrospinal fluid and neurophysiological investigations. No relationship was found between detrusor hypersensibility or detrusor hyposensibility and the aforementioned disease-related parameters. In 1 patient upper urinary tract abnormalities were noted in combination with urodynamic abnormalities. We conclude that lower urinary tract abnormalities can be found in every patient with multiple sclerosis unrelated to the state of the disease. Severe upper urinary tract abnormalities are rare.

Does it make sense to use two internal thoracic arteries?

Retrospectively, the first 143 patients who were operated on with bilateral internal thoracic arteries (BITA group) were matched with 143 patients operated on with only one left internal thoracic artery anastomosed on the left anterior descending artery and additional vein grafts (LITA group) and followed up for a maximum of 8 years. At 5 years follow-up there were no significant differences in event-free survival between the groups. After 8 years, the overall survival was 96% and 92% (not significant [NS]), cardiac survival 99% and 97% (NS), angina-free cardiac survival 51% and 35% (NS), infarction-free cardiac survival 95% and 78% (NS), reintervention-free cardiac survival 87% and 88% (NS), and all cardiac event-free survival 49% and 31% (NS) for the BITA and LITA groups, respectively. The incidence of late pulmonary, wound, and other complications was comparable. Cox proportional hazards analysis showed that a higher left ventricular end-diastolic pressure and female sex were predictors of recurrent angina and late cardiac events. During this intermediate-term follow-up, the use of one or two internal thoracic arteries was of no value in predicting angina-free or cardiac event-free survival.