Early catheter removal following transurethral prostatectomy--impact on length of hospital stay.

OBJECTIVE: To investigate whether early catheter removal following transurethral prostatectomy (TURP) is safe and whether it has any effect on the length of hospital stay. PATIENTS AND METHODS: Following transurethral prostatectomy 59 patients were randomized into one of two groups: those whose catheter was removed on day 1 after surgery and those whose catheter was removed on day 2. The incidence of complications and the duration of post-operative hospital stay were assessed. RESULTS: Catheter removal on day 1 led to a significantly shorter post-operative hospital stay (2.3 days versus 3.3 days) and did not incur a higher incidence of complications. CONCLUSIONS: Removal of the catheter on the first day following TURP is safe in selected patients and leads to a shorter post-operative hospital stay.

Laser lithotripsy with the Candela MDL-2000 LaserTripter.

The Yorkshire Lithotriptor Centre acquired a Candela MDL-2000 LaserTripter and a 7.2F Miniscope in February 1990. We present the results obtained in the first 200 patients referred for treatment of ureteric stones or stone fragments. Of 175 patients who were evaluable, 58 had upper ureteric stones, 41 mid-ureteric and 76 lower ureteric stones. Successful laser fragmentation was achieved in 77% of cases and a further 10% were rendered stone-free by the push-bang technique. Ureterolithotomy was required in 9% and the major complication rate was 4%. Ureteric dilatation was not used. Maximum laser energy was required to break 19% of the stones, but no stone was encountered which could not be broken. Laser lithotripsy with this system is highly effective at all levels of the ureter; it is safe and it complements ultrasound-guided extracorporeal lithotripsy.

Tamm-Horsfall protein as a marker in interstitial cystitis.

It has been suggested that immunohistochemical staining for Tamm-Horsfall protein in bladder epithelium may be a marker for interstitial cystitis. Of bladder biopsies from 14 interstitial cystitis patients only 3 demonstrated positive staining for Tamm-Horsfall protein within the mucosa, whereas 2 of 11 control biopsies showed positive Tamm-Horsfall protein results. In addition, staining in 4 ureteral specimens from interstitial cystitis patients and 4 controls was negative in all cases. An effort to detect this protein in enterocystoplasty specimens also showed a negative pattern. Our study does not confirm the Tamm-Horsfall protein as permeating either the bladder epithelium in interstitial cystitis or bowel mucosa in enterocystoplasty. This finding does not necessarily mean that these surfaces are not permeable to substances of smaller molecular size, nor does it define whether this is of importance in the etiology of interstitial cystitis. However, it does suggest that this technique does not allow detection of a marker for the disease.

Lymphocyte function in patients with interstitial cystitis.

To determine whether there is a primary immunological disorder involved in the etiology of interstitial cystitis, we compared the in vitro function of peripheral blood lymphocytes from 10 patients with interstitial cystitis to those from 10 healthy female controls. The lymphocytes were isolated and incubated in either cell culture medium alone, cell culture medium supplemented with the mitogen phytohemagglutinin or cell culture medium with autologous sterile filtered urine, the latter to detect any immunogenic potential of urine in this disease. We studied the relative proliferation of the phenotypes CD2, CD4, CD8, CD19, CD14 and CD56 by immunofluorescence and flow cytometry. To detect activation of T lymphocytes we also studied expression of HLA-Dr and interleukin-2 receptors. There was no difference in the rate of proliferation of the various lymphocyte phenotypes between the 2 groups in any of the culture media. Similarly, there was no difference between the 2 groups in the degree of lymphocytic activation after incubation. Furthermore, incubation in the presence of autologous urine caused no increase in activation above that seen in control cultures. We also assessed the production of the lymphokines interleukin-1, interleukin-2 and interferon-gamma in the supernatant fluid of the cell cultures. There was no difference in the production of these immunoregulatory cytokines between the control and patient groups, and again urine did not act as a mitogen in either group. We conclude from this study that there is no primary immunological disorder evident in patients with interstitial cystitis, and that the urine does not act as a stimulant to the immune system. This finding casts severe doubt on any theory suggesting that interstitial cystitis is an autoimmune disease or that urine contains an autoantigen causing the disease.

Use of an antibacterial powder spray to prevent post prostatectomy urinary infection.

To prevent ascending urinary infection in patients following transurethral prostatectomy, we have studied the use of a topical antibacterial agent applied to the groin and external genitalia. A prospective randomized controlled trial was conducted, with 50 patients being treated by daily application of a 2% polynoxylin powder, and 50 patients acting as untreated controls. Patient age and duration of catheterization were similar in the treated and untreated groups. No significant benefit was seen in the treated cohort (P greater than 0.05) in terms of reduction in postoperative urinary infection.

Cellular immunity in interstitial cystitis.

It has been suggested that interstitial cystitis is an autoimmune disease. The evidence for this hypothesis, based on studies of humoral immune factors, has been contradictory. We assessed the immune response in interstitial cystitis by evaluating lymphocyte populations in the peripheral blood and bladder tissue of interstitial cystitis patients. The lymphocyte phenotypes in peripheral blood were entirely normal, including the CD4 (cluster designation nomenclature) and CD8 subsets, and the CD4:CD8 ratio. Bladder lamina propria showed a predominance of CD4 over CD8 lymphocytes in interstitial and other forms of cystitis. Bladder epithelium showed a similar pattern in bacterial or mechanical cystitis but specimens from patients with interstitial cystitis had a predominance of CD8 cells. The findings of normal lymphocyte populations in the peripheral blood are not supportive of an autoimmune mechanism in the disease. The findings in bladder tissue show that the urothelium is not involved in the inflammatory reaction, as is the lamina propria, and they would suggest, therefore, that the initiating factor does not originate from the bladder lumen. The CD8 predominance in the urothelium along with a CD4 predominance in the lamina propria may form a characteristic pattern for the diagnosis of interstitial cystitis and merits further study.

Can histological assessment predict the outcome in interstitial cystitis?

In a retrospective study we compared the outcome of 39 patients with interstitial cystitis to the histological findings at initial diagnostic bladder biopsy. The degree of inflammation and fibrosis and the mast cell counts were assessed on each biopsy. The prognostic relevance of the clinical features of age, duration of symptoms, frequency, nocturia, pain and bladder capacity was assessed. The study showed no statistical correlation between the severity of histological findings at diagnosis and the eventual outcome of the disease. Over 50% of patients with severe histological abnormalities responded to conservative treatment. Although the majority of patients with mild pathological changes responded to conservative treatment, some did require surgical intervention. The clinical features of pain, nocturia and bladder capacity showed significant differences between the 2 patient groups. However, the former 2 features are subject to many variables and the latter probably has too wide a range to be useful as a prognostic indicator. Only the response of patients to conservative treatment will indicate those who are not being helped and who may eventually require surgical treatment.

Recurrent interstitial cystitis following cystoplasty: fact or fiction?

The severity of symptoms in interstitial cystitis may necessitate surgical treatment in approximately 10% of the patients. Substitution cystoplasty provides satisfactory results in most of these cases, while avoiding the need for urinary diversion. It has been suggested that interstitial cystitis may affect the bowel segment used in this form of operation. We studied bowel segments removed from cystoplasties in 5 patients with interstitial cystitis and compared these to bowel used for lower urinary reconstruction for other disorders in 6 patients. All segments showed varying degrees of inflammation, fibrosis and mastocytosis but there was no difference between the 2 groups for these features. We conclude that inflammation and fibrosis is the usual reaction of bowel to exposure to urine, and they do not represent a specific spread of interstitial cystitis in those patients. However, this reaction does mimic the histological appearance of interstitial cystitis in the bladder and may suggest a model for this disease.

Suppression of cellular immune activity following severe head injury.

Infection is a major cause of morbidity following multiple traumatic and head injury. Although immunosuppression has been demonstrated after multiple traumatic injury, the effects of head injury on immune function have not been thoroughly investigated. In a prospective study of 10 severely head-injured patients, in vitro and in vivo parameters of cellular immune activity were assessed. In vitro measurements of lymphocyte surface antigen expression following mitogen stimulation were made serially over a 3-week period in 10 patients with severe head injury. The control group consisted of 20 healthy subjects. Phenotyping of peripheral blood lymphocytes (PBLs) was performed following incubation with and without mitogens. Phenotypes were determined by flow cytometry using monoclonal antibodies (MABs) to T lymphocyte subsets and the alpha subunit of interleukin 2 (IL-2) receptors. In vivo cellular immune function was determined by measuring patient responses to delayed-type hypersensitivity (DTH) skin testing within 24 h of injury. When head-injured patients were compared to controls, PBLs incubated in the presence of phytohemagglutinin (PHA) demonstrated a decrease in cells marking as T cells (p = 0.005), helper-inducer T cells (p = 0.001), and in the number of IL-2 receptor-bearing cells (p = 0.001). The functional ability of these lymphocyte subpopulations to proliferate in the presence of PHA was significantly suppressed within 24 h of injury and normalized within 3 weeks of injury. DTH skin testing to Candida, mumps, trichophyton, and PPD antigens was performed within 24 h of injury and resulted in anergic responses in all 10 patients when measured at 24, 48, and 72 h following administration. The overall infection rate was 60%, with the majority of infections occurring within the first 4 days following injury. The results of this study indicate that severe head injury results in suppression of cellular immune function with a corresponding high rate of infection. The possible significance of the decrease in the percentage of helper-inducer T cells and in the number of cells bearing IL-2 receptors following mitogen stimulation is discussed.

Treatment and complications of Fournier's gangrene.

Ten patients with Fournier's gangrene were seen over an 11-month period; 3 had indwelling urethral catheters, 3 had preceding perineal infection and 6 had a history of alcohol abuse. An average of 2.1 operations was required per patient and the average hospital stay was 41 days. The mortality rate was 20%; 7 patients developed acute renal failure and 5 developed adult respiratory distress syndrome. Early treatment of these complications should help to reduce the mortality of this disease.

The split-cuff ureteral nipple reimplantation technique: reliable reflux prevention from bowel segments.

The split-cuff nipple ureteral implantation technique is described in 18 patients undergoing lower urinary tract reconstruction or supravesical diversion. This technique provides a simple and reliable antireflux mechanism into large and small bowel segments. No reflux or upper tract deterioration was seen initially, and only 1 case of mild reflux has occurred after 30 months of followup.

New method of postprostatectomy bladder irrigation.

Bacterial filters have been used to sterilise the hospital water supply in order to provide irrigant for postprostatectomy irrigation. This method was compared retrospectively to bladder irrigation derived from a still on the ward. Postoperative bacteriuria was similar in both groups of 75 patients, occurring in 23.7% of patients irrigated from the still and in 20% of patients irrigated via the filters. The bacterial filter proved reliable and as safe as using water from the still.