Intra-cavity side-pumped Ho:YAG laser.

We present a novel, compact and power scalable Ho:YAG laser based on intracavity side-pumping by a high-power Tm:YLF slab laser. 14 W of continuous wave output power is obtained at 2.09 microm in the current experiments, with the clear prospect of reaching the 100 W regime in a power scaled version.

Theory of 1- N-way phase-locked resonators.

A 1-N-way resonator based on beam splitting and beam combining effects in rectangular cross-sectional multimode waveguides was recently proposed. Such a resonator structure offers a valuable way in which N low-power laser elements may be combined in a coherent fashion. We examine the case of passive 1-N-way resonators. We develop a theory of these 1-N-way structures to show that there is only one possible mode of these resonators. The theory is used to give a scaling law for the design tolerances of the beam splitting and beam combining region of the resonator.

Theory of 1-N-way phase-locked resonators with perturbations in the array elements.

The recently proposed 1-N-way resonator based on beam splitting and beam combining effects in rectangular cross-sectional multimode waveguides offers a valuable way in which N low-power laser elements can be combined in a coherent fashion. We develop a theory of such resonators in the presence of perturbations in the N-element array. We demonstrate that despite the presence of perturbations there is only one possible mode of the resonator. The theory is used to provide an understanding of the effects of a number of possible perturbations that could arise as a result of manufacturing processes and operational effects. The results give scaling laws for the design tolerances on array element mirror tilt, array element optical path length control, and the effects of array element malfunction and their need for gain balance.

Ambulatory urodynamics: do they help clinical management?

OBJECTIVE: To assess the contribution of ambulatory urodynamics to the treatment of women with urinary incontinence. DESIGN: A retrospective casenote review of all women referred from the urogynaecology clinic for ambulatory urodynamic monitoring from 1 April 1994 to 31 December 1997. SETTING: A teaching hospital tertiary referral centre urodynamic laboratory. PARTICIPANTS: Notes were retrieved of 71 women, 80% of whom had had the investigation because the conventional cystometrogram had been normal. RESULTS: Technical difficulties occurred in 30 traces, two of which were not interpretable. Detrusor instability was diagnosed in 32 women, including three women who also had stress incontinence (42% of interpretable traces). Of these, 20 women were treated with anticholinergics compared with nine of 37 women where detrusor instability was not diagnosed. None of the women with detrusor instability were offered anti-incontinence surgery, compared with five of those where the bladder remained stable. Less than half the women who were treated with anticholinergic medication improved, but none were considered suitable for more aggressive treatment. CONCLUSIONS: Although the diagnosis of detrusor instability may be increased by ambulatory urodynamics, this does not always translate into more effective treatment. Ambulatory urodynamic testing does not yet result in clinical improvements in diagnosis and treatment.

Can uroflowmetry patterns in women be reliably interpreted?

Our aim was to investigate the proposition that uroflowmetry patterns can be reliably interpreted and correspond with specific urodynamic diagnoses. Uroflowmetry traces from 129 women with diagnoses of either genuine stress incontinence or detrusor instability were interpreted by four physicians with a minimum of 6 months experience in urogynecology. To test intraobserver variability, the traces were classified a second time 8 weeks later. Inter- and intraobserver variability was calculated by kappa analysis. There was marked intra- and interobserver variability in classification of traces, but no evidence of a correlation between urodynamic diagnosis and uroflowmetry pattern. Neither peak flow, total voided volume nor rate of acceleration of flow correlated with diagnosis. Although flow rates are important in predicting possible problems following surgery for stress incontinence, there is no evidence that flow patterns can be used as a screening test for specific urodynamic diagnoses.

Periurethral collagen injection: a long-term follow-up study.

OBJECTIVE: To determine the long-term success of the periurethral injection of collagen (Contigen(R), Bard UK) in women with genuine stress incontinence. PATIENTS AND METHODS: Sixty-one women with genuine stress incontinence were enrolled in a trial of periurethral collagen injections between 1 September 1990 and 31 August 1992. They were assessed at 1, 3, 6, 12 and 24 months after the last collagen injection. In 1998, their notes were reviewed, and a standardized questionnaire was sent to 46 women who were still alive and had undergone no further anti-incontinence surgery. RESULTS: Of the 53 women who were either known failures or who had follow-up information beyond 5 years, 26% were subjectively improved. Women who had a maximum urethral closure pressure of >20 cmH2O and those who had urinary incontinence for <10 years before their first injection were more likely to have had long-term success. There was no correlation between long-term success and the number of previous operations, body mass index, age or preoperative pad loss. Neither the number of injection sessions, total volume of collagen injected nor perceived bulking at the time of surgery affected long-term success rates. Of the 14 women who considered themselves subjectively improved, seven had daily incontinence and only one was completely dry. Urinary retention and urinary tract infection were the most common complications. In addition, one woman reported a flare-up of her skin test and transient 'flu-like symptoms 2 weeks after the injection, and one woman developed a right upper lobe pneumonia 2 weeks after the collagen injection. CONCLUSION: The long-term results of periurethral collagen injections are disappointing. We found no evidence to support the use of periurethral collagen injections in women with intrinsic sphincter deficiency, who had a higher failure rate than those with hypermobility. Further research is essential to develop agents that are not immunogenic, produce minimal inflammatory response and yet are durable.

Women's attitudes to urodynamics: a questionnaire survey.

OBJECTIVE: To obtain a measure of how well women tolerate urodynamic investigations and to determine how well they thought the test was explained. DESIGN: Prospective questionnaire survey. SETTING: A teaching hospital tertiary referral centre urodynamic laboratory. PARTICIPANTS: Three hundred and twenty-four women attending for urodynamic investigations on 331 occasions. Questionnaires were returned from 297 women (91.7%) with six women returning two questionnaires. RESULTS: Urodynamic investigations were well tolerated by most women, with 45% feeling that the procedure was not as bad as they expected. Moderate or severe anxiety about the test was experienced by 42% and 40% felt moderately or severely embarrassed. Pain was noted by 27% of women during investigation, and by 13% after investigation. Overall distress from the procedure was less in older women and in those who had been referred from a specialist urogynaecology clinic. Distress was higher when difficulties were encountered during the investigation and in women who had investigations other than a standard cystometrogram. Women were likely to find the test less distressing when they felt they had been given adequate information about the test. CONCLUSIONS: Although urodynamic investigations are generally well tolerated, there is a significant minority of women who find the test embarrassing, painful and distressing.

Iontophoresis as a new method of delivering local anesthesia to the urethra: a pilot study.

OBJECTIVES: To test the feasibility of using the iontophoretic catheter as a means of delivering local anesthetic (lidocaine hydrochloride) to the urethra for periurethral injection of collagen. METHODS: Eight women with urodynamically proven genuine stress incontinence underwent periurethral collagen injections. Local anesthesia was provided by 4% lidocaine with 1 in 100,000 epinephrine administered over 10 minutes using an iontophoretic catheter. Pain was assessed by Likert and visual analogue scales. Cystoscopic appearance of the urethra was noted. RESULTS: The periurethral bulking procedure was completed without further anesthetic in 7 women, 1 of whom had no pain. There was no evidence of urethral damage from the iontophoresis. CONCLUSIONS: Iontophoresis shows promise as a method of providing analgesia to the urethra. However, the degree of analgesia is variable, and further research is needed on catheter design to ensure transport of anesthetic agent into the periurethral tissues.

Male and female sterilisation.

PIP: Sexual sterilization is the major form of fertility control in women who are more than 30 years old. Clinicians usually use laparoscopy to perform female sterilization. They may occlude the fallopian tubes with a clip or ring or coagulate the tubes using bipolar diathermy. It is usually performed on an outpatient basis. Nonsteroidal anti-inflammatory drugs can generally control the postoperative pain. A serious immediate but rare complication is death, which is often associated with the anesthesia. Complications related to the experience of the surgeon include damage to bowel or blood vessels and tearing of mesosalpinx. Obesity or pelvic adhesions often necessitates either laparotomy or abandonment of sterilization. Some long term complications are hysterectomy and menstrual disorders. Presterilization counseling needs to examine the possibility of regret and to discuss failure rates and complications. Reasons for regret are young at time of sterilization, psychosexual disorder, change of partner, change in financial circumstances, sterilization performed at time of crisis, and death of a child. The failure rate for the Filshie clip is 0.1%. Reasons for failure include pregnant at the time of the procedure, clips placed across the round or ovarian ligament, incomplete occlusion, and fistula formation and recanalization. Failure rates are higher when the sterilization is done during pregnancy because the tubes are thicker and more vascular. Vasectomy involves severing and ligating the vas deferens in both scrotums. Immediate complications are hematoma and infection. Vasectomy patients need to bring 2 semen samples for sperm counts 3-4 months after the procedure. Azoospermia signals a successful vasectomy. If sperm are still present 5-6 months after the procedure, the surgeon should conduct exploratory surgery under general anesthesia. Long term side effects include testicular discomfort and perhaps prostate cancer. The evidence is unclear about the link between vasectomy and prostate cancer, however.^ieng

Atropine for the treatment of biliary tract pain: a double-blind, placebo-controlled trial.

STUDY OBJECTIVE: To compare the efficacy of IM atropine with placebo for the treatment of pain caused by biliary tract disease. DESIGN: Prospective randomized, double-blind, crossover study. SETTING: Emergency departments of a university medical center and affiliated county hospital. PARTICIPANTS: Fifty-five adults with biliary tract disease. INTERVENTIONS: Subjects were randomized to receive either 0.6 mg (0.5 mL) IM atropine or normal saline placebo in a double-blinded manner. If pain relief with the initial injection was inadequate, patients received the alternate injection. Pain was assessed by visual analog scale (0 to 100 mm) before the initial injection and 30 to 40 minutes after each subsequent injection. MEASUREMENTS AND MAIN RESULTS: Relief of pain was complete after the initial injection in four of 28 (14%) who received atropine and four of 27 (15%) who received normal saline (P = .956). For subjects who received both injections, atropine and placebo resulted in similar pain relief (-12.0 mm versus -16.0 mm; P = .316). There also was no difference in pain relief between atropine and placebo for the subset of patients with biliary colic receiving both injections (-15.2 mm versus -17.0 mm; P = .658). This study had more than 80% power to detect a 7.5-mm difference in pain relief between atropine and placebo in all patients with biliary tract disease and a 12.5-mm difference in those with biliary colic. CONCLUSION: Atropine is no better than placebo in the treatment of biliary tract pain.