International standards to document remaining autonomic function after spinal cord injury.

STUDY DESIGN: Experts opinions consensus. OBJECTIVE: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI). BACKGROUND AND RATIONALE: The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function. METHODS: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function. RESULTS: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function. CONCLUSION: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

Divertículo uretral femenino. A propósito de un caso / Female urethral diverticula. A propos of one case

OBJETIVO: Se describe la reparación transvaginal de un divertículo uretral grande y complejo. Se ha realizado una revisión y análisis crítico de la epidemiología, los métodos diagnósticos, tratamientos y complicaciones de los divertículos uretrales femeninos. PACIENTES Y MÉTODOS: Una mujer de 35 años consultó por goteo terminal, dispareunia e infecciones urinarias de repetición durante cuatro meses. Las imágenes de resonancia magnética nuclear mostraron dos formaciones líquidas en la pelvis de 3,5 y 1 cm de tamaño, respectivamente, que podían corresponder a un gran divertículo complejo, sin poder descartar un quiste de la glándula de Bartolino. En la cistouretroscopia se encontró un divertículo uretral a 10 mm del cuello vesical, con dos ostium. Se realizó una diverticulectomía transvaginal con colgajo de la pared anterior vaginal. Se identificó y analizó la literatura publicada de divertículo uretral femenino mediante la búsqueda en Pubmed Medline. RESULTADOS: Convalecencia sin complicaciones. El tubo de cistostomía suprapúbica se retiró 2 semanas después de la intervención. La paciente recuperó la micción normal. En la literatura publicada no hay consenso ni en los métodos de diagnóstico ni en las técnicas quirúrgicas para los divertículos vesicales femeninos. CONCLUSIONES: Los divertículos uretrales se diagnostican cada vez con más frecuencia. Sin embargo, continúan pasando desapercibidos porque los síntomas simulan otros trastornos. La cistouretroscopia, el uretrograma retrógrado mediante el catéter de doble balón y últimamente las imágenes de resonancia magnética nuclear pueden diagnosticar esta patología. Con la indicación quirúrgica adecuada, se curan el 86-100 por ciento de los divertículos uretrales. La extirpación completa a través de la pared vaginal anterior es el mejor tratamiento con las mínimas complicaciones post-operatorias (AU)

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[Female urethral diverticulum. Report of a case]. / Divertículo uretral femenino. A propósito de un caso.

PURPOSE: We describe the successful repair of a large and complex urethral diverticulum in a female by transvaginal approach. Epidemiology, diagnostic methods, treatments and complications of female urethral diverticula are reviewed. PATIENTS AND METHODS: A 35-year-old woman with a history of postvoid dribbling, dyspareunia and recurrent urinary tract infections for 4 months was referred. Magnetic resonance imaging demonstrated two fluido-filled collections in the pelvis of 3.5 and 1 cm in size respectively which may be a very large and complex diverticulum, however, Bartholin gland cyst could not be rule out. Cystourethroscopy revealed a urethral diverticulum at 10 mm from the bladder neck with two ostia. It was performed transvaginal diverticulectomy and an anterior vaginal wall flap was placed. The published literature on female urethral diverticula was identified using a Pubmed Medline search and analysed. RESULTS: Convalescence was unremarkable. Suprapubic cystostomy tube was removed 2 weeks after surgery. The patient regained normal voiding. In the published literature there are no agreement neither in the diagnostic nor in the surgical techniques for female urethral diverticula. CONCLUSIONS: Urethral diverticula are diagnosed with increasing frequency. However, this entity continues to be overlooked because the symptoms may mimic other disorders. Cystourethroscopy, retrograde urethrograme using a double balloon catheter and recently magnetic resonance imaging may diagnose this disease. The cure rate of urethral diverticula with appropriate surgical management has a range of 86-100%. Complete excision through the anterior vaginal wall is the most successful treatment modality with minimum postoperative complications.

Artificial urinary sphincter for post-radical prostatectomy urinary incontinence: long-term subjective results.

PURPOSE: Incontinence affects between 3% and 60% of patients after radical prostatectomy. Insertion of an artificial urinary sphincter is a mainstay therapeutic option available to these patients. We assessed patient satisfaction, outcome and complications long after artificial urinary sphincter implantation. MATERIALS AND METHODS: From a data bank of 131 patients who underwent artificial urinary sphincter prosthesis insertion we identified 71 with a mean age of 72 years who had also undergone radical prostatectomy and were available for evaluation. This group included 29 patients (40.8%) who received an earlier version of the AMS-800 (American Medical Systems, Minnetonka, Minnesota) and 42 (59.2%) who received the newer narrow back cuff device. Information on surgical procedures and followup were obtained from a computerized database. Patients were also contacted by an impartial reviewer who administered a standard telephone questionnaire on the degree of continence, complications, other means used to help with urinary continence, proficiency in device operation and satisfaction. RESULTS: At a mean followup of 7.7 years (range 0.5 to 16) 19 patients (27%) used 0, 23 (32%) used 1, 11 (15%) used 1 to 3 and 18 (25%) used more than 3 daily, while 1 used an external catheter. Surgical revision in 21 cases (29%) was required due to mechanical failure in 18 (25%), device erosion in 3 (4%) and infection in 1 (1.4%). The need for revision correlated significantly with the design of the sphincter (p = 0.005). Only 7 of the 42 patients in whom a narrow cuff AMS-800 was implanted needed revision versus 18 of the 23 with a previous design. Mean time to revision was 2.5 years (range 0.5 to 8). The device was removed in 2 cases (2.8%). Of the patients 41 (58%) are very satisfied, 14 (19%) are satisfied and 16 (23%) are unsatisfied with the device. The degree of satisfaction correlated with the number of pads used (p = 0.0005) and sphincter design (0.028) but not with the number of surgical revisions (p = 0.521) or patient age. CONCLUSIONS: The artificial urinary sphincter is a viable treatment option for post-radical prostatectomy incontinence with a high rate of continence and satisfaction for a long period after the procedure. Patients should be informed that complications necessitating device revision and explantation may appear late in followup. A standard definition of treatment success and studies of homogenous groups of patients with an artificial urinary sphincter would enable better understanding and patient education in the future.

Fixed and dynamic urethral compression for the treatment of post-prostatectomy urinary incontinence: is history repeating itself?

PURPOSE: We reviewed the evolution of appliances and devices used for treating post-prostatectomy urinary incontinence. MATERIALS AND METHODS: We used the MEDLINE to search the literature from 1966 to March 2000 and then manually searched bibliographies to identify studies that our initial search may have missed. RESULTS: The evolution of treatment for post-prostatectomy urinary incontinence may be traced back to the 18th century. Two main schools of thoughts simultaneously evolved. The first fixed urethral compression devices were constructed to enable urethral obstruction by fixed resistance. This outlet resistance allows voiding after intra-abdominal and intravesical pressure is elevated but it is sufficient to prevent leakage between urinations. The other school of thought preferred creation of dynamic urethral compression in which outlet resistance is not fixed but may be decreased when voiding is desired or elevated between urinations. Therapeutic fixed and dynamic urethral compression interventions may be further divided into external or internal compressive devices or procedures. External fixed compression devices may be traced back to antiquity. A penile clamp, similar to the later Cunningham clamp, and a truss designed to compress the urethra by external perineal compression were presented in the Heister textbook of surgery, Institutiones Chirurgicae, as early as 1750. Dynamic compressive devices applied externally were developed much later, such as the first artificial urinary sphincter, described by Foley, in 1947 and the Vincent apparatus, described in 1960. The modern era of fixed urethral compression began in 1961 with Berry. Acrylic prostheses impregnated with bismuth to allow radiographic visualization were produced in various shapes and sizes, and used to compress the urethra against the urogenital diaphragm. In 1968 the University of California-Los Angeles group under the direction of Kaufman began to use cavernous crural crossover to compress the bulbous urethra (Kaufman I). Later 2 other modifications were described, including approximation of the crura in the midline using a polytetrafluoroethylene mesh tape (Kaufman II) and an implantable silicone gel prosthesis (Kaufman III). With the advent of the artificial urinary sphincter pioneered by Scott in 1973 interest in passive urethral compression disappeared in favor of the implantation of an inflatable circumferential prosthetic sphincter. Recently there has been a trend back to passive urethral compression. Synthetic bolsters have been described that passively compress the bulbar urethra to achieve urinary incontinence after radical prostatectomy. CONCLUSIONS: Much creativity has been dedicated to solve the complex and challenging problem of post-prostatectomy urinary incontinence. Devices used for treating this condition may be grouped according to the mechanism of action and how they are applied. Passive urethral compression, long abandoned in favor of dynamic implantable sphincters, has reemerged. Further research in this field may determine which school of thought may provide the best solution for treating post-prostatectomy urinary incontinence.

Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary?

Objectives. To evaluate the use of interposition flaps in repairing vesicovaginal fistulas (VVFs) of benign and malignant etiologies. Interposition flaps are not routinely used in the repair of VVFs when the surrounding tissues appear healthy and well-vascularized, such as in a benign etiology.Methods. We retrospectively reviewed the charts of 37 women (mean age 49.1 years) at our institution who underwent transabdominal repair of their VVF by urologic surgeons between August 1978 and June 1999. The preoperative and postoperative medical records were reviewed.Results. Of the 37 VVFs repaired transabdominally, 29 had a benign etiology (25 related to gynecologic procedures) and 8 a malignant etiology (all related to gynecologic neoplasia). Of the 29 benign VVFs, an interposition flap was used in 10 repairs with all 10 successful (100%). The remaining 19 benign VVF repairs were performed without using a flap, with 12 successful (63%). Of the 8 malignant fistulas, an interposition flap was used in 2 repairs with both successful (100%). The remaining 6 malignant VVF repairs were performed without a flap, with 4 successful (67%).Conclusions. The results of our study indicate a higher success rate for transabdominal VVF repairs performed with an interposition flap (100% success rate at our institution). This observation holds true regardless of the appearance of healthy surrounding tissue or, more importantly, a benign or malignant etiology. We recommend interposition flaps in transabdominal repairs of VVFs, even in the cases of benign fistulas with well-preserved surrounding tissue.

[Acute urinary retention secondary to clear cell adenocarcinoma of the urethra]. / Rétention urinaire aiguë secondaire à un adénocarcinome à cellules claires de l'urèthre.

The authors report a case of primary clear cell cancer of the urethra in a woman presenting with acute urinary retention. The diagnosis was based on cystoscopy and confirmed by histological examination of urethral biopsies. Treatment consisted of urethrocystectomy with creation of an "Indiana pouch". The pathological stage was T3N2M0 [1]. Three months postoperatively, the patient presented with inguinal lymph node metastases. She was treated with 3 courses of chemotherapy (mitomycin and 5-fluorouracil) combined with radiotherapy. With a follow-up of 10 months, the patient is still alive and inguinal lymph nodes have regressed. This case report emphasizes the rarity of this histological type and describes the management of urinary retention in a woman when an underlying specific disease is suspected.

Collaboration and practice patterns among urologists and gynecologists in the treatment of urinary incontinence and pelvic floor prolapse: a survey of the International Continence Society members.

Both urologists and gynecologists are involved in the care of women with urinary incontinence (UI) and pelvic floor prolapse (PFP). This study was designed to examine the differences among urologists and gynecologists who treat UI and PFP, and to characterize the collaboration between them. A 14-question survey was mailed to the International Continence Society (ICS) members who are urologists or gynecologists. Questions dealt with professional training, type of practice, volume of UI and PFP procedures, preferred procedures for various types of UI and PFP, and the type and extent of collaboration. Of the 666 urologists and gynecologists to whom the questionnaire was sent, 229 responded (34.4% response rate). Among them, 63.7% were urologists and 36.2% were gynecologists. Collaboration in the operating room was reported by 140 responders (50.7%) and was significantly correlated with the specialty, and with the country of practice, with P values of 0.004, and 0.004, respectively. Collaboration in the operating room was reported mainly in procedures for the correction of vaginal vault prolapse or enterocele, and hysterectomy. It was not statistically correlated with the time dedicated to UI and PFP, the volume of surgeries performed, UI and PFP fellowship training, university hospital affiliation, and years in practice. Reasons for not collaborating in the operating room included familiarity with all or most of the anti-incontinence and pelvic floor reconstruction procedures (44.5%), unavailability of the other professional (6.1%), and reimbursement problems (3.1%). While urologists and gynecologists do collaborate extensively in clinical research and diagnosis of challenging cases, surgical collaboration is limited to procedures traditionally performed by gynecologists. Future training programs exposing trainees to both fields of expertise may enable better ground for collaboration and improved care for women with UI and PFP.

Postirradiation vesicovaginal fistula completely resolved with conservative treatment.

Postirradiation vesicovaginal fistulae (VVF) pose a great challenge for the urologist. The poorly vascularized radiated tissue surrounding the fistula impairs healing and makes operative repair technically demanding. Conservative treatment for postirradiation VVF is considered inappropriate, and to our knowledge has never previously been described. We present a case of a woman with postirradiation VVF that was resolved after transurethral coagulation and 3 weeks of catheterization.

Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis.

PURPOSE: We assessed the merit of dynamic half Fourier acquisition, single shot turbo spin-echo sequence T2-weighted magnetic resonance imaging (MRI) for evaluating pelvic organ prolapse and all other female pelvic pathology by prospectively correlating clinical with imaging findings. MATERIALS AND METHODS: From September 1997 to April 1998, 100 consecutive women 23 to 88 years old with (65) and without (35) pelvic organ prolapse underwent half Fourier acquisition, single shot turbo spin-echo sequence dynamic pelvic T2-weighted MRI at our institution using a 1.5 Tesla magnet with phased array coils. Mid sagittal and parasagittal views with the patient supine, relaxed and straining were obtained using no pre-examination preparation or instrumentation. We evaluated the anterior vaginal wall, bladder, urethra, posterior vaginal wall, rectum, pelvic floor musculature, perineum, uterus, vaginal cuff, ovaries, ureters and intraperitoneal organs for all pathological conditions, including pelvic prolapse. Patients underwent a prospective physical examination performed by a female urologist, and an experienced radiologist blinded to pre-imaging clinical findings interpreted all studies. Physical examination, MRI and intraoperative findings were statistically correlated. RESULTS: Total image acquisition time was 2.5 minutes, room time 10 minutes and cost American $540. Half Fourier acquisition, single shot turbo spin-echo T2-weighted MRI revealed pathological entities other than pelvic prolapse in 55 cases, including uterine fibroids in 11, ovarian cysts in 9, bilateral ureteronephrosis in 3, nabothian cyst in 7, Bartholin's gland cyst in 4, urethral diverticulum in 3, polytetrafluoroethylene graft abscess in 3, bladder diverticulum in 2, sacral spinal abnormalities in 2, bladder tumor in 1, sigmoid diverticulosis in 1 and other in 9. Intraoperative findings were considered the gold standard against which physical examination and MRI were compared. Using these criteria the sensitivity, specificity and positive predictive value of MRI were 100%, 83% and 97% for cystocele; 100%, 75% and 94% for urethrocele; 100%, 54% and 33% for vaginal vault prolapse; 83%, 100% and 100% for uterine prolapse; 87%, 80% and 91% for enterocele; and 76%, 50% and 96% for rectocele. CONCLUSIONS: Dynamic half Fourier acquisition, single shot turbo spin-echo MRI appears to be an important adjunct in the comprehensive evaluation of the female pelvis. Except for rectocele, pelvic floor prolapse is accurately staged and pelvic organ pathology reliably detected. The technique is rapid, noninvasive and cost-effective, and it allows the clinician to visualize the whole pelvis using a single dynamic study that provides superb anatomical detail.

Life-threatening anaphylactoid reaction associated with indigo carmine intravenous injection.

Indigo carmine (sodium indigotindisulfonate), a blue dye, has been widely used by surgeons to identify and to examine the urinary tract and is considered biologically inert and extremely safe. We present a case of severe life-threatening anaphylactoid reaction followed by cardiac arrest associated with intravenous indigo carmine injection.

Current investigations and treatment of interstitial cystitis.

Interstitial cystitis (IC) is a chronic condition characterized by a constellation of symptoms such as urinary frequency, nocturia, urinary urgency, suprapubic pressure, and bladder and pelvic pain. Since its original description, the etiology of the disorder has remained unknown despite intense investigations. The International Cystitis Association (ICA) and the National Institutes of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) have been instrumental in supporting the United States Interstitial Database (ICDB) and foster research to study the disorder. The NIDDK developed criteria to ensure that all groups of patients treated would be relatively comparable. However, many patients who would be clinically considered to have IC do not fulfill all the NIDDK criteria. Many clinical criteria for the diagnosis of IC, such as the presence of glomerulations and the intravesical potassium chloride test, are being challenged. The epidemiology of the disorder is not well established, but there are an estimated 700,000 cases of IC in the United States. Numerous pathophysiologic mechanisms have been proposed, but none have been proven. There is no representative animal model of IC. Both the oral and intravesical treatments of IC are noncurative, and few are based on a plausible mechanism or scientific evidence. Surgical treatment should be considered with extreme caution; it is the last therapeutic option because failure rate can be substantial.

Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging.

OBJECTIVES: With significant vaginal prolapse, it is often difficult to differentiate among cystocele, enterocele, and high rectocele by physical examination alone. Our group has previously demonstrated the utility of magnetic resonance imaging (MRI) for evaluating pelvic prolapse. We describe a simple objective grading system for quantifying pelvic floor relaxation and prolapse. METHODS: One hundred sixty-four consecutive women presenting with pelvic pain (n = 39) or organ prolapse (n = 125) underwent dynamic MRI. The "H-line" (levator hiatus) measures the distance from the pubis to the posterior anal canal. The "M-line" (muscular pelvic floor relaxation) measures the descent of the levator plate from the pubococcygeal line. The "O" classification (organ prolapse) characterizes the degree of visceral prolapse beyond the H-line. RESULTS: The image acquisition time was 2.5 minutes per study. Each study cost $540. In the pain group, the H-line averaged 5.2 +/- 1.1 cm versus 7.5 +/- 1.5 cm in the prolapse group (P <0.001). The M-line averaged 1.9 +/- 1.2 cm in the pain group versus 4.1 +/- 1.5 cm in the prolapse group (P <0.001). Incidental pelvic pathologic features were commonly noted, including uterine fibroids, ovarian cysts, hydroureter, urethral diverticula, and foreign body. CONCLUSIONS: The HMO classification provides a straightforward and reproducible method for staging and quantifying pelvic floor relaxation and visceral prolapse. Dynamic MRI requires no patient preparation and is ideal for the objective evaluation and follow-up of patients with pelvic prolapse and pelvic floor relaxation. MRI obviates the need for cystourethrography, pelvic ultrasound, or intravenous urography and has become the study of choice at our institution for evaluating the female pelvis.

4-Defect repair of grade 4 cystocele.

PURPOSE: The 4-defect repair of grade 4 cystocele corrects discrete and severe deficiencies of vesicourethral support. We describe this technique used during pelvic reconstruction in 130 women. MATERIALS AND METHODS: During a 3-year period 130 patients (age range 35 to 96 years) underwent repair of grade 4 cystocele using the 4-defect repair technique. Cystocele repair had been performed in 60 patients (46%) and hysterectomy had been performed in 85 (65%). A "goalpost incision" is used in the vaginal wall to facilitate separation of the wall from underlying perivesical fascia, entry into the retropubic space, and exposure of the urethropelvic ligament, cardinal ligament and perivesical fascia. The 4 polypropylene sutures are used to provide an anterior vaginal wall sling which is modified to incorporate perivesical fascia and cardinal ligaments. Central defect repair is achieved by approximation of the cardinal ligaments and midline plication of the perivesical fascia over absorbable mesh. RESULTS: A total of 112 patients were available for followup which ranged from 6 to 42 months (mean 21). Repair of grade 4 cystocele was accompanied by other transvaginal repairs in 94 patients (83%), including rectocele repair in 81, hysterectomy in 22 and enterocele repair in 31. Of the patients 92% had excellent objective and subjective results for anatomical cystocele repair. Of the patients with preoperative stress urinary incontinence 90% had excellent or good subjective results. De novo urge incontinence was seen in 7% of patients. CONCLUSIONS: The 4-defect repair technique relies on anatomical restoration of 4 distinct deficiencies of pelvic support and is highly effective for relief of symptoms of grade 4 cystocele.

Refashioned short bowel segments for the construction of catheterizable channels (the Monti procedure): early clinical experience.

PURPOSE: We report the early results of a new surgical procedure to construct a catheterizable stoma from a small segment of bowel according to the Monti technique. MATERIALS AND METHODS: Since November 1996, 4 male and 4 female patients with a mean age of 14 years have undergone the Monti procedure in association with other reconstructive efforts. Indications included the unavailability of appendix because of concomitant ACE Malone appendicocecostomy in 2 patients, atretic appendixes in 3, previous appendectomy in 2 and technical difficulties during appendix isolation in 1. In no patient was small bowel used instead of a suitable appendix. Other simultaneous surgical procedures included bladder augmentation in 4 patients in whom the bowel tube and patch for augmentation were created with the same mesenteric pedicle (ileum in 3 and sigmoid colon in 1). RESULTS: Followup ranged from 3 to 11 months (mean 7). No patient has had difficulty with catheterization or any other problems related to the stoma. In 2 patients stomal leakage required additional procedures and pharmacological manipulation. CONCLUSIONS: The appendiceal Mitrofanoff procedure remains the technique of choice for the construction of catheterizable continent stomas. In the absence of a suitable appendix a catheterizable bowel conduit based on the Monti technique appears to be the best alternative in our early experience. The short segment of bowel required for conduit construction, excellent blood supply throughout its length, and the possibility of developing the tube and bowel patch for simultaneous augmentation from the same pedicle are some of the clear advantages of this technique.

Reconstruction and undiversion of the short or severely dilated ureter: the antireflux ileal nipple revisited.

PURPOSE: Patients undergoing reconstruction of short or severely dilated aperistaltic ureters are at significant risk for mechanical or functional obstruction and reflux, particularly when the ureters are being reimplanted into gastric or intestinal segments. For this problem we describe a simple handsewn, "stapleless" antireflux ileal nipple, which serves as a useful bridge between a short ureter and the bladder or reservoir. MATERIALS AND METHODS: A total of 12 patients, 4 to 42 years old (mean age 19), 9 with severely dilated and 3 with short ureters have received the stapleless antireflux ileal nipple as part of various reconstructive efforts. Briefly, a 12 to 15 cm. segment of ileum is isolated and the mesentery is stripped from the middle 8 cm. of the isolated segment, preserving the blood supply to the proximal and distal 2 cm. of ileum. Intussusception is created and maintained with multiple (5 to 7) circumferential rows of 4 to 6 interrupted seromuscular stitches of 3-zero silk. RESULTS: Mean followup is 27.5 months (range 6 to 60). Upper tract dilatation has stabilized or improved in all patients, deteriorating temporarily in 1 who had distal nipple stenosis. All patients underwent followup video urodynamic studies, which demonstrated no reflux. Nipple related complications included nipple stenosis in 1 patient and dessusception in another. Both complications were corrected without sequelae. Ureteroileal stenosis or stone formation has not occurred. CONCLUSIONS: The stapleless antireflux ileal nipple is safe and reliable in preventing reflux. It is a versatile adjunct to urinary reconstruction in patients with short or severely dilated, aperistaltic ureters in whom the alternative of a tapered reimplantation into a segment of bowel or stomach poses a significant complication threat.