Combined transurethral prostatectomy and inguinal hernia repair: a retrospective audit and literature review.

OBJECTIVE: To audit the results of combined transurethral resection of the prostate (TURP) and inguinal hernia repair, often carried out under the same anaesthetic (because bladder outlet obstruction from prostatic disease and inguinal hernia are both common conditions in elderly men), to avoid two separate operations. PATIENTS AND METHODS: The study included 85 patients who underwent primary inguinal hernia repair with TURP in the urology unit of Nottingham City hospital between 1989 and 1995, and who were recalled to a special clinic. The type of hernia and repair carried out were recorded and complications audited with specific reference to recurrence of hernia and wound infection. RESULTS: The 85 patients underwent 88 primary inguinal hernia repairs with TURP (three were bilateral). Maloney's darn repair was used on 55 and a Bassini repair on 33 occasions, respectively. Two patients developed mild wound infection after surgery, but only two patients (2%) had recurrence of hernia. CONCLUSIONS: The recurrence rate after primary inguinal herniorraphy with conventional methods of repair, performed with TURP, was comparable with published results of hernia repairs alone, before the introduction of Lichtenstein's mesh repair.

Peri-urethral silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence.

OBJECTIVE: To establish the safety and efficacy of the periurethral injection of silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence in women. PATIENTS AND METHODS: Forty women (median age 50 years, range 27-74) with genuine stress incontinence confirmed on medium-fill video-cystometry were recruited to the study. Macroplastique (3-7 mL) was injected periurethrally 1 cm distal to the bladder neck at three or four points 'around the clock' under cystoscopic control. Where possible, the urodynamic study was repeated after 3 months. Results were graded as excellent (dry, no protection), good (better, but not totally dry) or poor (no improvement). RESULTS: Three months after a single injection, 16 (40%) were completely dry, 13 (33%) were improved and 11 (27%) were no better. Four patients who were improved were rendered dry by a second injection. After 3 years, 16 (40%) remained completely dry, seven (18%) were improved and 17 (42%) required alternative treatment with a Stamey bladder neck suspension. Dysuria for 48 h occurred in almost all patients; two were catheterized overnight and one required a catheter for 6 weeks. A comparison of maximum voiding pressures and flow rates before and 3 months after a single injection of Macroplastique revealed no urodynamic evidence of obstructed voiding (n = 25). CONCLUSION: Injectable silicone microimplants produced a good to excellent result in 73% of patients in the short-term and 58% of women maintained this response after 3 years. The injection is a day-case procedure which provides a satisfactory medium-term outcome in over half of patients with genuine stress incontinence. There are few side-effects and those patients with no improvement may go on to be treated by open surgery without complication.

Expression of muscarinic M3-receptors coupled to inositol phospholipid hydrolysis in human detrusor cultured smooth muscle cells.

PURPOSE: To investigate the effect of muscarinic receptor agonists and antagonists on the accumulation of inositol phosphates in cultures of human detrusor smooth muscle cells. MATERIALS AND METHODS: Primary explant culture was used to derive smooth muscle cell lines from small bladder biopsies. The cells were loaded with [3H]-myoinositol, stimulated with muscarinic agonists, and the accumulation of [3H]-inositol phosphates was measured by liquid scintillation counting. RESULTS: Carbachol (EC50 8.3 microM.), methacholine (EC50 7.5 microM.), oxotremorine (EC50 2.5 microM.) and pilocarpine (EC50 8.3 microM.) produced concentration-dependent rises in the accumulation of total [3H]-inositol phosphates. M1 (pirenzepine), M2 (methoctramine) and M3 (4-DAMP and pf-HHSiD) muscarinic receptor antagonists significantly antagonized the response induced by a submaximal concentration of carbachol (100 microM.). The apparent pA2 values were atropine (9.4), 4-DAMP (9.2), pfHHSid (7.4), pirenzepine (6.9) and methoctramine (6.3). CONCLUSIONS: These results indicate that human detrusor smooth muscle cells in culture express M3 muscarinic receptors which are linked to phosphoinositide hydrolysis.

A urodynamic study of laser ablation of the prostate and a comparison of techniques.

OBJECTIVE: To evaluate the effect of laser ablation of the prostate on symptomatic and urodynamic parameters and to compare laser delivery systems. PATIENTS AND METHODS: The study comprised 81 patients of whom 79 were waiting for transurethral resection of the prostate (TURP) and two who presented in acute urinary retention. The 79 patients (median age 65 years, range 45-82) underwent pre-operative urodynamics and all patients completed American Urological Association (AUA) symptom score questionnaires before surgery. Visually-guided laser ablation of the prostate (VLAP) was performed and the urodynamics and symptom scores were repeated 3 months later. RESULTS: The improvements in symptom scores and flow rates were statistically significant and comparable with other published data. There were also significant improvements in voiding pressure. There were no significant differences between the various laser fibres used. There were few complications. CONCLUSION: The effectiveness of VLAP in improving symptoms and flow rates in patients with benign prostatic hyperplasia (BPH) is confirmed. The procedure also reduced voiding pressure, confirming the relief of bladder outflow tract obstruction. VLAP is confirmed as a safe and effective treatment for BPH. Continued follow-up is needed to determine the long-term effects.

Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures.

OBJECTIVE: To ascertain the duration of intermittent low-friction self-catheterization (ILSC) required to cause stricture stabilization. PATIENTS AND METHODS: Over a 4 year period, 101 patients with a median age of 62 years (range 16-85) with recurrent urethral strictures were recruited to the trial. All the strictures were treated by internal urethrotomy and the patients were then randomized to perform ILSC twice weekly for either 6 months (group 1) or 36 months (group 2). Out-patient follow-up with urinary flow rate was initially at 1 month and then at 3 monthly intervals. Stricture recurrence rates were compared between the two groups. RESULTS: Of 101 patients, seven failed to attend after the first out-patient appointment. A further 21 died of unrelated disease whilst on ILSC (although 13 had been followed up for at least 24 months and so were included in the analysis). The median follow-up was 67 months (range 24-78). Ten patients in group 2, who had suffered from recurrent strictures, refused to stop catheterizing at the appointed time and all remain stricture-free on permanent ILSC. Of the remaining 76 patients, 48 catheterized for 6 months and 28 patients performed ILSC for 12 to 36 months (nine stopped earlier than intended). Forty per cent of patients who stopped at 6 months developed a recurrence compared with 14% who catheterized for more than 12 months (P < 0.05) (chi-square test with Yates' correction). CONCLUSIONS: Our results indicate that ILSC is safe and effective in preventing stricture recurrence in the long term. The recurrence rate of urethral strictures was significantly lower when ILSC was continued for more than 12 months compared with ILSC that was stopped at 6 months. We conclude that catheterization for at least 1 year is required to achieve adequate urethral stabilization.

Computerised audit for colorectal cancer.

An audit has been performed of cases of colorectal cancer presenting over an 8-year period. The results of 242 patients are discussed with emphasis placed on the process of surgical audit. In particular, the ease of data handling by a computer database system is stressed. The figures produced on age, sex, presentation, diagnosis, treatment and outcome have allowed a more detailed and fruitful discussion of our practice at the monthly audit meeting.

Amiodarone prophylaxis for tachycardias after coronary artery surgery: a randomised, double blind, placebo controlled trial.

BACKGROUND: Arrhythmias are a common cause of morbidity after cardiac surgery. This study assessed the efficacy of prophylactic amiodarone in reducing the incidence of atrial fibrillation or flutter and ventricular arrhythmias after coronary artery surgery. METHODS: A double blind, randomised, placebo controlled trial. 60 patients received a 24 hour intravenous infusion of amiodarone (15 mg/kg started after removal of the aortic cross clamp) followed by 200 mg orally three times daily for 5 days, and 60 patients received placebo. RESULTS: 6 patients (10%) in the amiodarone group and 14 (23%) in the placebo group needed treatment for arrhythmias (95% confidence interval (95% CI) for the difference between groups was 0 to 26%, p = 0.05). The incidence of supraventricular tachycardia detected clinically and requiring treatment was lower in the amiodarone group (8% amiodarone v 20% placebo, 95% CI 0 to 24%, p = 0.07). The incidence detected by 24 hour Holter monitoring was similar (17% amiodarone v 20% placebo). Untreated arrhythmias in the amiodarone group were either clinically benign and undetected (n = 3) or the ventricular response rate was slow (n = 2). Age > 60 years was a positive risk factor for the development of supraventricular tachycardia in the amiodarone group but not in the placebo group. Fewer patients had episodes of ventricular tachycardia or fibrillation recorded on Holter monitoring in the amiodarone group (15% amiodarone v 33% placebo, 95% CI 3 to 33%, p = 0.02). Bradycardia (78% amiodarone v 48% placebo, 95% CI 14% to 46%, p < 0.005) and pauses (7% amiodarone v 0% placebo) occurred in more amiodarone treated patients. Bradycardia warranted discontinuation of treatment in one patient treated with amiodarone. CONCLUSIONS: The incidence of clinically significant tachycardia was reduced by amiodarone. The ventricular response rate was slowed in supraventricular tachycardia, but the induction of bradycardia may preclude the routine use of amiodarone for prophylaxis.

Paraoesophageal hiatal hernias: when to operate.

Between 1979 and 1988, 29 cases of paraoesophageal hernia presented to one surgeon (F.D.S.). There were 23 women and six men and the mean(s.e.m.) age was 66.3(4.1) years. All were symptomatic and 13 hernias (45%) were complicated by gastric volvulus, haemorrhage or perforation. Ten (34%) had evidence of gastro-oesophageal reflux, suggesting a sliding component in these cases. Operation, mostly transthoracic, consisted of hernial reduction, crural repair and, if indicated, an antireflux procedure. There were three deaths. Two occurred as a result of spontaneous, intrathoracic perforation of the hernia. The third followed dilatation of a benign stricture 2 months after surgery. The only major complication was a pulmonary embolus with full recovery. The mean(s.e.m.) follow-up time was 47.6(7.8) months and there were no recurrences. This series confirms that symptomatic paraoesophageal hernias warrant early repair because of the frequency and severity of associated complications. Although debate continues as to whether this policy should be extended to asymptomatic paraoesophageal hernias, we suggest that this should be so.

Management of intercostal drains.

Intercostal tubes are inserted to treat several intrathoracic calamities. As these conditions may present to any hospital specialty, every doctor should be capable of placing a drain successfully. Equal importance must be attached to the subsequent care of the drain. This report outlines the correct procedure for managing intercostal drains and describes the complications that may occur.