Abnormalities of plantar pressure distribution in early, intermediate, and late stages of diabetic neuropathy.

Inconsistent findings with regard to plantar pressure while walking in the diabetic population may be due to the heterogeneity of the studied groups resulting from the classification/grouping criteria adopted. The clinical diagnosis and classification of diabetes have inherent uncertainties that compromise the definition of its onset and the differentiation of its severity stages. A fuzzy system could improve the precision of the diagnosis and classification of diabetic neuropathy because it takes those uncertainties into account and combines different assessment methods. Here, we investigated how plantar pressure abnormalities evolve throughout different severity stages of diabetic polyneuropathy (absent, n=38; mild, n=20; moderate, n=47; severe, n=24). Pressure distribution was analysed over five areas while patients walked barefoot. Patients with mild neuropathy displayed an increase in pressure-time integral at the forefoot and a lower peak pressure at the heel. The peak and pressure-time integral under the forefoot and heel were aggravated in later stages of the disease (moderate and severe) compared with early stages of the disease (absent and mild). In the severe group, lower pressures at the lateral forefoot and hallux were observed, which could be related to symptoms that develop with the aggravation of neuropathy: atrophy of the intrinsic foot muscles, reduction of distal muscle activity, and joint stiffness. Although there were clear alterations over the forefoot and in a number of plantar areas with higher pressures within each severity stage, they did not follow the aggravation evolution of neuropathy classified by the fuzzy model. Based on these results, therapeutic interventions should begin in the early stages of this disease to prevent further consequences of the disease.

EAU guidelines on surgical treatment of urinary incontinence.

CONTEXT: The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology. OBJECTIVE: We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience. EVIDENCE ACQUISITION: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system. EVIDENCE SUMMARY: The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report. CONCLUSIONS: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]. / Guía clínica de la Asociación Europea de Urología sobre la evaluación y el tratamiento no quirúrgico de la incontinencia urinaria.

CONTEXT: The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology. OBJECTIVE: We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination. EVIDENCE ACQUISITION: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system. EVIDENCE SUMMARY: The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice. CONCLUSIONS: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

Effect of a rocker non-heeled shoe on EMG and ground reaction forces during gait without previous training.

Unstable shoes have been designed to promote "natural instability" and during walking they should simulate barefoot gait, enhancing muscle activity and, thus, attributing an advantage over regular tennis shoes. Recent studies showed that, after special training on the appropriate walking pattern, the use of the Masai Barefoot Technology (MBT) shoe increases muscle activation during walking. Our study presents a comparison of muscle activity as well as horizontal and vertical forces during gait with the MBT, a standard tennis shoe and barefoot walking of healthy individuals without previous training. These variables were compared in 25 female subjects and gait conditions were compared using ANOVA repeated measures (effect size:0.25). Walking with the MBT shoe in this non-instructed condition produced higher vertical forces (first vertical peak and weight acceptance rate) than walking with a standard shoe or walking barefoot, which suggests an increase in the loads received by the musculoskeletal system, especially at heel strike. Walking with the MBT shoe did not increase muscle activity when compared to walking with the standard shoe. The barefoot condition was more effective than the MBT shoe at enhancing muscle activation. Therefore, in healthy individuals, no advantage was found in using the MBT over a standard tennis shoe without a special training period. Further studies using the MBT without any instruction over a longer period are needed to evaluate if the higher loads observed in the present study would return to their baseline values after a period of adaptation, and if the muscle activity would increase over time.

Multivisceral resection for primary locally advanced rectal carcinoma.

BACKGROUND: Pelvic multivisceral resection offers the possibility of cure in patients with locally advanced rectal cancer. This study assessed the clinical outcome and determinants of survival and local recurrence in patients undergoing multivisceral resection for clinical T4 primary rectal cancer. METHODS: This was a cohort study of consecutive multivisceral resections carried out in a single centre from 2000 to 2009. Determinants of local recurrence and survival were examined by means of Kaplan-Meier survival curves and Cox regression analysis. RESULTS: The study included 42 patients, with a median age of 62 (range 41-83) years, who underwent surgery with a median follow-up of 30 (range 2-102) months. Thirty-one patients had preoperative chemoradiotherapy. Seven patients had rectal resection with en bloc radical prostatectomy. The 30-day mortality rate was zero. Thirty-nine of the 42 patients had a negative circumferential resection margin. The 5-year overall survival rate for those who had complete resection was 48 per cent. Local recurrence was predicted by metastatic disease (P < 0.001) and nodal disease (P < 0.001), but not positive resection margins (P = 0.077). CONCLUSION: An aggressive surgical strategy with complete resection is predictive of long-term survival in selected patients with T4a rectal carcinoma. With optimal treatment local recurrence is a sign of systemic disease.

Quality and quantity: an audit of urodynamics practice in relation to newly published National Standards.

OBJECTIVE: To document urodynamic practice in Wales in relation to newly released National Minimum Standards with a view to influencing organisational change. METHODS: Three questionnaires, evaluating respectively, departmental practice, individual practice and the last 10 studies performed in that department, were sent to all departments performing urodynamics in Wales. Results 19/20 departments responded. Approximately 4,000 studies are performed annually in Wales. Three departments do not perform enough studies annually to meet minimum standards. The minimum standard of 30 studies annually is not met by most centers evaluating neuropathic patients or performing ambulatory tests. Eighty four percent of departments have a clinical lead, one quarter discuss urodynamics in the context of a multi-disciplinary team meeting and occasional audits are performed. Fifty-four staff perform urodynamics, of which 35 (65%) have attended a course. Ability to describe zeroing a transducer was scored out of 6 and respondents scored a median of 3/6. One hundred twenty two out of 168 (72%) of the studies audited asked a clear urodynamics question, but, in 22/168 (13%) this question was not answered. The urodynamics report was written immediately 85% of the time. CONCLUSION: Centers failing to meet the minimum standards for workload should consider their position in relation to standards and NICE guidance (UKCS, NICE). In particular, departments should give attention to standards described in "Good Urodynamic Practice," establish multi-disciplinary teams for continence management and consider greater centralization of investigations for patients with neuropathies and for ambulatory studies. Most staff attended a course, yet few can describe how to zero transducers. This raises questions about the quality of reporting of some urodynamic studies. Those that are involved in urodynamics should take part in regular CME, relevant audit and consider certification and revalidation. This audit has highlighted significant variations in practice and lends support to the application of nationally agreed standards.

A randomised controlled trial comparing TVT, Pelvicol and autologous fascial slings for the treatment of stress urinary incontinence in women.

OBJECTIVE: To compare TVT(TM) , Pelvicol(TM) and autologous fascial slings (AFSs). DESIGN: A multicentre randomised control trial. SETTING: Four units in the UK. POPULATION: Women requiring primary surgery for stress urinary incontinence (SUI). METHODS: A total of 201 women with urodynamically proven stress incontinence were randomised into three groups and assessed at baseline, 6 weeks, 6 months and 1 year. MAIN OUTCOME MEASURE: The primary outcome was patient-reported improvement rates. Secondary outcomes included operative complications/time, intermittent self-catheterisation (ISC) and re-operation rates. The quality-of-life tools used were the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) and EuroQoL. RESULTS: Fifty women had a Pelvicol(TM) sling, 79 had AFSs and 72 had TVT(TM). At 6 months the Pelvicol(TM) arm had poorer improvement rates (73%) than TVT(TM) (92%)/AFS (95%); P=0.003. At 1 year only 61% of the Pelvicol(TM) slings remained as improved, versus 93% of TVTs and 90% of AFSs (P<0.001). Pelvicol(TM) has poorer dry rates (22%) than TVT(TM) (55%)/AFS (48%) (P=0.001) at 1 year; hence, the Pelvicol(TM) arm was suspended following interim analysis. There is no difference in the success rates between TVT(TM) and AFS. One in five women in the Pelvicol(TM) arm had further surgery for SUI by 1 year, but none required further surgery in the other arms. AFS took longer to do (54 minutes versus 35 minutes for TVT(TM) /36 minutes for Pelvicol(TM) ) and had higher ISC rates (9.9 versus 0% Pelvicol(TM) /TVT(TM) 1.5%). Hospital stay was shortest for TVT(TM) (2 days). Most BFLUTS domains showed improvement in all three arms. The improvement for women in the Pelvicol(TM) arm, however, was less than for women in the other arms in several key domains. CONCLUSIONS: Pelvicol(TM) cannot be recommended for the management of SUI. TVT(TM) does not have greater efficacy than AFS, but does utilise fewer resources.

Static single channel and multichannel water perfusion pressure profilometry in a bench model of a urethra.

AIMS: To determine the catheter perfusion and withdrawal rate which generate the most repeatable single (SCPP) and multichannel pressure profilometry (MCPP) profiles in a bench model. METHODS: A bench model using a urethral substitute was developed in which SCPP and MCPP were performed using the Brown-Wickham method. One single channel and four multichannel catheters were tested using seven withdrawal rates and three perfusion rates. Repeatability was determined using spread of mean profile pressure, cross-correlation, Bland-Altman statistic, and a one-tailed Student's t-statistic. An artificial urinary sphincter (AUS) model was constructed to create a predictable intraluminal profile. MCPP data were used to generate three-dimensional (3D) images of the pressures exerted by the AUS model. RESULTS: A withdrawal rate of 0.5 mm/sec and perfusion rate 1 ml/min produced the most repeatable SCPP profiles with a spread of mean profile pressure ≤7 cmH(2)O. For MCPP, a 10 F 6-channel catheter using a withdrawal rate of 1 mm/sec and perfusion rate of 1 ml/min produced the most similar profiles (cross-correlation = 0.99). However, the spread of MCPP was large (spread ≤44 cmH(2)O per channel). Nevertheless MCPP was able to consistently demonstrate areas of high pressure as predicted by the AUS model. CONCLUSIONS: MCPP was not repeatable and is an unreliable measure of urethral pressure. MCPP and 3D images do demonstrate directional differences predicted from the AUS model. These may be of use for qualitative understanding and appreciation of relative relationships if not actual forces within the urethra and have application in understanding urethral function in vivo.

Botulinum toxin B is not an effective treatment of refractory overactive bladder.

OBJECTIVES: To determine the efficacy and safety of botulinum toxin-B (BTX-B) in two groups of patients with urodynamically proven idiopathic detrusor overactivity (IDO) or neurogenic DO (NDO) refractory to conservative treatment. METHODS: This was a nonrandomized, prospective study. We diluted 5000 U of BTX-B in 20 mL of normal saline and injected it at 20 sites around the bladder, avoiding the trigone. The data collected at recruitment and 10 and 26 weeks postoperatively included number of incontinent episodes, frequency, and nocturia, King's Health Questionnaire score, and the urodynamic parameters of volume at the first overactive contraction and maximal cystometric capacity. RESULTS: A total of 25 patients were recruited, 20 with IDO and 5 with NDO. Only 7 patients, all with IDO, reported symptomatic improvement at the 10-week assessment. The symptoms had returned in these 7 patients at a median of 136 days (range 106 to 151) after injection. Of the remaining 20 patients, 16 (13 with IDO and 3 with NDO) thought an initial improvement had occurred but it had worn off or was wearing off by the first assessment. Two patients (both with NDO) reported no improvement. CONCLUSIONS: BTX-B had a limited duration of action, with most of its symptomatically beneficial effects wearing off by 10 weeks in most of our patients. The short duration of action for BTX-B suggests it is unlikely to gain widespread use in the treatment of DO.

Exenterative pelvic surgery--eleven year experience of the Swansea Pelvic Oncology Group.

AIMS: To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group. PATIENTS AND METHODS: Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery. RESULTS: Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis. CONCLUSION: With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.

Urogenital infection by Mycobacterium bovis relapsing after 50 years.

A 64-year-old man was referred to chest clinic after presenting initially with painless haematuria. Bladder biopsies showed granulomatous inflammation and subsequent urine cultures grew Mycobacterium bovis. He had been treated empirically for genito-urinary tuberculosis twice previously and on both occasions his haematuria ceased. Although the early hospital notes have been destroyed we believe this represents a very late and recurrent relapse of cystitis due to M. bovis.

Urinary tract ultrasonography in the evaluation of haematuria--a report of over 1,000 cases.

Over a 5-year period, 1007 patients with haematuria were investigated, using a protocol based on ultrasonography as the upper tract imaging modality of choice. Intravenous urography (IVU) was only used in selected individuals, including those patients with bladder cancer suspected on cystoscopy, suspicious or malignant cytology, previous investigation for haematuria, on-going haematuria at the time of their clinic visit, a history of flank pain or hydronephrosis on ultrasonography. Of this series, 840 (83%) had visible haematuria, 158 (15%) had microscopic or chemical haematuria and 9 (0.9%) had unspecified haematuria. A total of 133 bladder transitional cell tumours, 21 renal cell cancers and 2 upper tract transitional cell cancers (TCC) were diagnosed. The sensitivity of ultrasound with respect to bladder cancer was 63% and the specificity 99%. The odds ratio of diagnosing cancer in patients with visible haematuria compared to microscopic or unspecified haematuria was 3.3. No upper tract tumours were missed using this investigational protocol. An ultrasonography-based protocol could miss fewer upper tract TCCs than a standard IVU-based service would miss renal cell cancer. Provided there is no history of flank pain, no malignant cytology, no hydronephrosis and no previously investigated haematuria, IVU could be safely omitted.

Identification of metastatic disease by T category, gleason score and serum PSA level in patients with carcinoma of the prostate.

Pre-operative serum prostate specific antigen (Tandem-R assay), T category, Gleason score and the metastatic (M1) status of a consecutive series of 60 patients with newly diagnosed carcinoma of the prostate were studied prospectively. The results revealed that, of these variables, pre-operative serum PSA (greater than 100 ng/ml) was the single most important indicator of metastatic disease, with 100% predictive value. With this alone, 83.3% of M1 disease could be correctly identified. For the remaining 17%, however, we advocate a high index of suspicion if the tumour is T3-T4 category on digital rectal examination (predictive value = 71.4%) and has a high grade with a Gleason score 8-10 (predictive value = 81%).

Sperm retrieval by electro-ejaculation. Preliminary experience in patients with secondary anejaculation.

Twelve patients with spinal cord injury and 2 diabetics with secondary anejaculation underwent 26 sessions of electro-ejaculation, using a technique which has previously been popular only in veterinary medicine. Ejaculate was obtained on 21 occasions. Semen quality was adequate for cryostorage on 9 occasions (8 patients); on 8 occasions (5 patients) it was used for immediate artificial insemination of the partner. To date, there has been 1 pregnancy resulting in a live birth.

Lumbosacral evoked potentials and vesicourethral function in patients with chronic suprasacral spinal cord injury.

Persistent detrusor acontractility despite normal somatic reflex activity in some patients with high spinal cord injury is an enigma. Previous work has suggested disordered integration of afferent activity in sacral roots or the sacral spinal cord. Forty male patients with chronic stable suprasacral cord lesions were studied by filling and voiding videocystometrography, and recording lumbosacral evoked potentials from posterior tibial nerve stimulation. Only five of 15 patients with decreased detrusor contractility had abnormal lumbosacral evoked potentials. Similar abnormalities were found in four of 11 patients with efficient hyperreflexic bladders. The finding of normal lumbosacral evoked potentials in the majority of patients with suprasacral cord injuries and decreased detrusor contractility supports the argument that the pathophysiology of this specific form of neurogenic bladder dysfunction is multifactorial.

Idiopathic constipation associated with impaired urethrovesical and sacral reflex function.

Sixteen chronically constipated women (age range 20-66 years) and 29 healthy control subjects (age range 22-53 years) underwent neurophysiological assessment of the integrity of pelvic spinal reflexes. The results were compared with videourodynamic studies and multiport anorectal manometry combined with external anal sphincter electromyography. The neurophysiological assessment consisted of electrical stimulation of the dorsogenital nerve, while recording any evoked reflex activity in the external anal and urethral sphincters with concentric needle and surface electrodes. Of these constipated women, 75 per cent had absence of one or more evoked sacral reflexes (compared with 20 per cent of healthy controls, P less than 0.05). Sensory thresholds and motor unit potentials in the external anal sphincter were similar in healthy and constipated women. Nine (56 per cent) constipated women displayed urodynamic abnormalities (increased bladder capacity, acontractile bladder and genuine stress incontinence). Only 38 per cent of constipated women perceived a desire to defaecate during rectal distension with up to 100 ml, compared with 95 per cent of normal subjects (P less than 0.0005). Moreover, 73 per cent of constipated women did not relax the external anal sphincter during defaecation, compared with 12 per cent of controls (P = 0.001). Taking into account the possible significance of our data in relation to previous findings it is suggested that the integration of sensory information within the sacral cord may be impaired in chronic idiopathic constipation.

Characterization of the serum In(Lu)-related antigen: identification of a serum protein related to erythrocyte p80.

The In(Lu) gene has been shown previously to downregulate expression by erythrocytes and by a subset of leukocytes of an 80-Kd protein antigen defined by monoclonal antibody (MoAb) A3D8. A3D8 antibody has also been shown by inhibition studies to recognize a serum antigen; this serum antigen is present in reduced amount in serum from In(Lu) donors. The present study demonstrates that the serum antigen recognized by A3D8 antibody also resides on a protein similar in size to the protein present in erythrocyte membranes. Studies using chromatographically purified protein have further shown that this antigen shares many epitopes with that present in RBCs and is therefore likely to be extremely homologous or identical to the erythrocyte In(Lu)-related p80.

Lack of relationship of conus reflexes to bladder function after spinal cord injury.

A series of 20 patients with acute complete suprasacral cord lesions underwent serial urodynamic assessment of vesicourethral function and serial measurement of sacral reflex latency times (SRL) and reflex threshold throughout a follow-up period of 42 to 83 weeks (mean 50). No correlation was found between any pattern of SRL latencies or reflex thresholds and subsequent bladder behaviour. The reproducibility of sacral reflex latencies was found to be poor (mean variation of serial measurements from initial reading 21%) and could not be explained on the basis of "dynamic" neurological recovery. Studies using the bladder as a stimulus site were unreliable. The value of SRL studies in detecting subtle neurophysiological changes is discussed.