'Will you be doing my operation doctor?' Patient attitudes to informed consent.

BACKGROUND: As part of the consent process, it is part of a doctor's duty of care to reveal any material risk. Depending upon the level of supervision, whether the operating surgeon is a trainee may be such a risk, but in our experience this is not routinely discussed with patients pre-operatively. We set out to discover patients' attitudes to being operated on by trainee urological surgeons. PATIENTS AND METHODS: A total of 101 completed questionnaires were received from patients (90 male, 11 female, mean age 72 years) undergoing transurethral resection of the prostate (TURP), transurethral resection of a bladder tumour (TURBT) or cystodiathermy on various aspects of their attitudes to being operated on by junior doctors as part of training. RESULTS: The response rate was 77%. Of the respondents, 94 patients (91%) thought that junior doctors should perform surgery as part of their training. Only 11 of 73 (15%) said they would be happy for a junior doctor, competent to perform the procedure, to operate unsupervised. Of 98 patients, 80 (82%) thought they should be told if the operation was going to be performed by a junior doctor, and 85 (87%) that they should be told their name and designation. CONCLUSIONS: For consent to be 'informed', the experience and identity of the surgeon should be made known to patients. Most patients are happy to be operated on by a junior doctor under consultant supervision, but would want to be told and know their name and status.

An open-label pilot study of cannabis-based extracts for bladder dysfunction in advanced multiple sclerosis.

The majority of patients with multiple sclerosis (MS) develop troublesome lower urinary tract symptoms (LUTS). Anecdotal reports suggest that cannabis may alleviate LUTS, and cannabinoid receptors in the bladder and nervous system are potential pharmacological targets. In an open trial we evaluated the safety, tolerability, dose range, and efficacy of two whole-plant extracts of Cannabis sativa in patients with advanced MS and refractory LUTS. Patients took extracts containing delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD; 2.5 mg of each per spray) for eight weeks followed by THC-only (2.5 mg THC per spray) for a further eight weeks, and then into a long-term extension. Assessments included urinary frequency and volume charts, incontinence pad weights, cystometry and visual analogue scales for secondary troublesome symptoms. Twenty-one patients were recruited and data from 15 were evaluated. Urinary urgency, the number and volume of incontinence episodes, frequency and nocturia all decreased significantly following treatment (P <0.05, Wilcoxon's signed rank test). However, daily total voided, catheterized and urinary incontinence pad weights also decreased significantly on both extracts. Patient self-assessment of pain, spasticity and quality of sleep improved significantly (P <0.05, Wilcoxon's signed rank test) with pain improvement continuing up to median of 35 weeks. There were few troublesome side effects, suggesting that cannabis-based medicinal extracts are a safe and effective treatment for urinary and other problems in patients with advanced MS.

The role of the human bladder lamina propria myofibroblast.

OBJECTIVES: To describe the ultrastructure and relationship to nerves of the myofibroblast in the human bladder lamina propria, and discuss its possible role in bladder function, including sensing stretch, as the response of the bladder to stretch has been thoroughly investigated by afferent nerve recordings, but specialized stretch sensing organs have yet to be identified. MATERIALS AND METHODS: Flexible cystoscopic bladder biopsies were obtained from patients with detrusor hyper-reflexia and from controls. Systematic electron micrographs were obtained throughout the lamina propria, and the presence and location of cells with ultrastructural characteristics of myofibroblasts noted, together with their relation to surrounding nerves. RESULTS: Within the lamina propria there was a layer of cells with the cytological characteristics of both fibroblasts and smooth muscle cells, that included bundles of fine cytoplasmic filaments, dense bodies, linear arrays of subsurface vacuoles, and the presence of an interrupted basal lamina. This combination of features is characteristic of the myofibroblast. These cells had close contacts with unmyelinated axonal varicosities containing a mixture of clear and large dense-cored vesicles, or clear vesicles alone. CONCLUSIONS: There is a layer of cells with the ultrastructural characteristics of myofibroblasts within the human bladder lamina propria. Their close contacts with nerves containing both small clear, and small clear with dense-cored, vesicles implies they have both an efferent and an afferent nerve supply, possibly functioning as a bladder stretch receptor. Furthermore, because of their similarities with the interstitial cells of Cajal in the gut, which are claimed to modulate small intestinal function, we discuss other possible roles for bladder lamina propria myofibroblasts.

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.

A Pacinian corpuscle in the human bladder lamina propria.

The fortuitous finding of a complex Pacinian corpuscle within the lamina propria of the human urinary bladder is described. It consisted of a complex of encapsulated nerve endings within the areolar connective tissue of the lamina propria immediately adjacent to the inner aspect of the detrusor muscle. It showed no structural evidence of directional sensitivity and was associated on its outer aspect with small unmyelinated axons containing small clear and dense-cored vesicles. This appears to be the first report of an encapsulated nerve ending within the lining of the adult human urinary bladder.