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PURPOSE: All urethral reconstruction that involves substitution has an inherent ongoing incidence of restenosis with time. Anastomotic restoration of urethral continuity naturally obviates these complications but to achieve its potential of a long-term stricture-free success rate that approaches 100% circumstances must be ideal and the reconstructive surgical technique must be meticulous. If the critical indications for anastomotic reconstruction are overextended, complications inevitably increase. Considerable additional urethral length is required to overcome the terminal atretic deficiency associated with hypospadias and create a tension-free anastomotic neomeatoplasty. Mobilization and advancement of the penile urethra alone are rarely sufficient to achieve this without causing penile chordee. We describe the details of bulbar elongation anastomotic meatoplasty (BEAM) that we have been using for approximately the last 8 years. MATERIALS AND METHODS: The only part of the urethra that can be mobilized to provide extra length for anastomotic urethroplasty without creating penile curvature chordee is the bulbar urethra. Full length mobilization of the whole length of the bulbar urethra through a perineal incision provides 2 to 2.5 cm. of tension-free lengthening in children and 4 to 5 cm. in adults. Thus, many subterminal urethral deficiencies can be resolved by bulbar elongation anastomotic meatoplasty when the total extent of the urethral deficiency is not disproportionally long. We performed bulbar elongation anastomotic meatoplasty in 12 patients 2 to 25 years old. RESULTS: At a followup of 2 to 7 years the neomeatus is functionally and cosmetically satisfactory in all cases with no long-term complications or chordee. CONCLUSIONS: When circumstances are appropriate, bulbar elongation anastomotic meatoplasty is a preferable alternative to some of the current substitution procedures. Once established, anastomotic reconstructions are generally stable in the long term.

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The principal aim of this study was to provide an objective assessment of the potential role of urethral pressure profilometry as a technique for assessing prostatic size by direct comparison with endoscopic assessment of prostatic length and computed tomographic measurement of prostatic volume and length. There was a poor correlation between pre-operative prostatic length and amount resected in the operating theatre. The results obtained with urethral pressure profilometry correlated poorly with those obtained using the other techniques, and cannot therefore be relied upon in routine clinical practice. Although there was good correlation between the length of the prostate and prostatic size, assessed by pre-operative computed tomography, this correlated poorly with the amount of tissue resected at operation. Further studies need to be conducted to compare objectively the completeness of prostatic resection with the outcome following prostatectomy.

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A series of 24 patients underwent 27 transtrigonal phenol injections for the treatment of bladder instability. Only 2 of 18 patients with detrusor instability and 2 of 6 with detrusor hyperreflexia continued to derive benefit from the procedure 6 months after it was carried out. Serious complications attributable to phenol were seen in 2 patients in this series and in a further 4 patients referred for complications resulting from this therapy in other centres. These results and a review of the literature lead us to suggest that transvesical phenol injection should not be used except in the hyper-reflexic bladder when no alternative treatment is possible. Particular care should be exercised in patients who have undergone extensive prior surgery or radiotherapy.

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A young man with psychologic problems and a long history of social inadequacy presented with voiding dysfunction. Videocystometrography revealed a normal filling phase and normal initiation of voiding interrupted by considerable straining by the patient and marked sphincter electromyographic (EMG) activity. Temporary amelioration was achieved by infiltration of the sphincter with lignocaine hydrochloride and by biofeedback therapy. In such cases optimal results are expected from long-term behavioral therapy.

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The main prevalence of vesicoureteric reflux (VUR) is in the adult female population. Although recognised as a clinical entity in adult males, little detailed information is available on this subject. A retrospective analysis was carried out on the results of 1519 consecutive videocystometrograms performed on male patients. VUR had an overall incidence of 8.6% within this population, with a range of 5.1% in patients with normal urodynamics to 15.6% in those with detrusor-sphincter dyssynergia. The common denominator between VUR and urodynamic measurement appears to be the generation of high intravesical pressures. These findings suggest that VUR is not uncommon in the male population, is usually asymptomatic and should respond to the treatment of any underlying bladder abnormality.

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The aetiology of pain in interstitial cystitis is not understood, although it has been reported to be due to release of mediators from mast cell granules. Cystolysis and intravesical instillation of dimethyl sulphoxide have been shown to relieve pain in this condition. We have studied the nerve population within the bladder wall using immunohistochemical stains for protein gene product 9.5. A group of 18 cases of chronic interstitial cystitis and 12 controls; neuropathic bladder (n = 1), chronic bacterial cystitis (n = 3), systemic lupus erythematosus cystitis (n = 2) and normals (n = 6), were investigated. There were significantly more nerve fibres within the sub-urothelial and detrusor muscle layers in chronic interstitial cystitis than there were in normals. Patients with chronic cystitis of other aetiology did not have a significant increase in nerve fibre density within the bladder wall suggesting a specific association between nerve fibre proliferation and interstitial cystitis. Cystolysis is shown to deplete selectively the submucosal nerve plexuses without altering the nerve density within detrusor muscle. This finding explains the desensitisation of the bladder without impairment of detrusor function after this procedure.

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Radioligand receptor binding and autoradiography were used to characterize, localize and compare alpha-1 and alpha-2 adrenoceptors and muscarinic cholinergic receptor populations in human benign prostatic hyperplastic tissue. The binding of selective alpha-1 and alpha-2 ligands, [3H]-prazosin and [3H]-UK 14,304, to homogenates of human central and peripheral prostate was saturable and of high affinity. Scatchard analysis produced an equilibrium dissociation constant (KD) of 0.51 +/- 0.10 nM for alpha-1 adrenoceptors, and 2.34 +/- 0.40 nM for alpha-2 adrenoceptors. The mean densities, Bmax, of alpha-1 and alpha-2 adrenoceptors identified in the human adenomatous prostate were 65.9 +/- 12.9 and 36.1 +/- 7.0 fmoles/mg. protein respectively. Receptor autoradiography was used to examine the distribution of muscarinic cholinergic receptors [( 3H]-QNB), alpha-1 adrenoceptors [( 3H]-prazosin]), and alpha-2 adrenoceptors [( 3H]-rauwolscine) on consecutive sections of benign hyperplastic prostatic tissue. Although both subtypes of adrenoceptor were seen in the stromal component of the hyperplastic prostate, there was a substantial predominance of alpha-1 adrenoceptors. A densitometric computer-assisted analysis was performed on the autoradiographic slides to determine the mean ratio of specific alpha-1: alpha-2 adrenoceptors in the stromal compartment of the hyperplastic tissue. The ratio, expressed as % grain occupancy/unit area, was 3.9 +/- 0.75, which is in agreement with a functional alpha-1 adrenoceptor predominance shown in previous studies. Although sparsely distributed in the stroma, a dense alpha-2 adrenoceptor population was seen in association with blood vessels, and in close proximity to the base of some of the [3H]-QNB-labelled prostatic glandular epithelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

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Benign prostatic enlargement is a common cause of bladder outlet obstruction. Recent work has demonstrated the important role played by the sympathetic nervous system in the control of prostatic muscle tone. Although isometric muscle strip studies and clinical trials have highlighted the influence of alpha-1 adrenoceptors, radioisotope ligand binding studies have demonstrated a relatively increased density of alpha-2 adrenoceptors in the muscle within prostatic tissue, the significance of which is as yet unexplained. Forty patients entered a study using pharmacological muscle strip experiments, radioligand binding assays and receptor autoradiography. Pharmacological data from these studies confirmed that contraction of prostatic muscle is mediated predominantly by alpha-1 adrenoceptor stimulation, with no evidence of significant alpha-2 adrenoceptor or cholinergic mediated effects. Radioligand binding studies confirmed that there is a higher concentration of alpha-1 binding sites as contrasted to alpha-2 within normal prostate, but that this relationship approaches equity in adenomatous prostate. Autoradiographic localisation demonstrated that alpha-1 adrenoceptor binding is predominant within prostatic stroma with only a small component of alpha-2 adrenoceptors in this compartment. This comprehensive study supports the suggestion that prostatic muscular contraction is controlled by the influence of the sympathetic nervous system acting via alpha-1 adrenoceptors. These findings support the therapeutic use of specific alpha-1 adrenoceptor blockade in the management of benign prostatic hyperplasia.

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The accuracy, reliability and cost effectiveness of 5 currently marketed flow meters have been assessed. The mechanics of each meter is briefly described in relation to its accuracy and robustness. The merits and faults of the meters are discussed and the important features of flow measurements that need to be taken into account when making diagnostic interpretations are emphasised.

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The instillation of diluted Bonney's blue into the bladder during gynaecological operations has been quite common practice over the last 50 years. Bonney's blue is composed of a 1:1 mixture of brilliant green and crystal violet dissolved in ethanol (90%) or industrial methylated spirit. Before insertion into the bladder this solution must be diluted with water to a 0.5% solution. Failure to do this will result in a severe inflammatory reaction within the bladder. The degree of resultant damage depends upon the duration of exposure. Persistent pain is a feature of this condition, although the other symptoms (frequency and urgency) may settle in time. Two cases of chemical cystitis resulting from the use of undiluted Bonney's blue are described to illustrate the possible consequences. Both patients were awarded 6-figure sums as compensation.

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The endoscopic subtrigonal injection of a 6% aqueous phenol solution is an effective technique for denervating the bladder but its clinical usefulness is limited by unpredictable side effects. This study explored the possibility of making this procedure safer by comparing the neurolytic effects of different concentrations and carriers of phenol. Phenol in 2.5 and 5% solutions in three different carriers (water, glycerine and oil) was injected into the rectovesical pouch in 35 rats. After 3 weeks the bladders were excised and the effects on the density of acetylcholinesterase-positive nerves were assessed in each animal using morphometric techniques. The density of enzyme-containing nerves was reduced by 20% in the phenolised animals when compared with controls. This reduction was maximum when water was used as the carrier for either 2.5 or 5% phenol solutions.

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Eleven patients who suffered persistent bladder dysfunction after pelvic surgery have been investigated by needle urethral sphincter electromyography (EMG) and bladder muscle biopsy, and the results compared with those obtained in a series of controls. Individual motor units recorded from the urethral sphincter in patients who had undergone pelvic surgery were strikingly abnormal, suggesting the presence of reinnervation, and the density of detrusor innervation was significantly reduced. However, since reduction in the density of detrusor innervation may occur in circumstances other than peripheral nerve injury, we conclude that urethral sphincter EMG provides the most effective means of assessing damage to vesico-urethral innervation as a result of previous pelvic surgery.

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Ten men with longstanding idiopathic Parkinson's disease (IPD) were investigated by urodynamic and electromyographic methods. The urodynamic studies were repeated after stopping anti-Parkinsonian medication for several hours. All patients showed a difference between the two studies, but the changes were unpredictable. Three patients who had high residual urine volumes in both studies were thought to have prostatic obstruction. EMG analysis showed no evidence of a lower motor neurone lesion affecting the striated urethral sphincter. It was concluded that micturition difficulty in the patient with IPD is due to detrusor hyperreflexia, influenced by the basal ganglia, which is not associated with impaired striated urethral sphincter activity.

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Two hundred and fifty patients have been studied by synchronous cine/pressure/flow cystometry to assess the relationship between radiological trabeculation and the urodynamic findings. There is a strong association between detrusor instability and trabeculation. Trabeculation, however, may also occur in the presence of high pressure outflow obstruction, usually at prostate level, in the absence of instability. It is suggested that frequent uninitiated detrusor contraction against a voluntarily closed sphincter is a likely cause of the more prominent varieties of trabeculation. However, the presence of minor degrees of trabeculation noted at cystoscopic examination in the absence of detrusor instability is not disputed.

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Sixty-four patients with normal bladder function, stress incontinence, idiopathic instability or instability associated with enuresis underwent pressure/flow videocystography. This was repeated from one month to 8 years later (average 19.4 months). Filling cystometry remained qualitatively unchanged in 95% of cases overall, whilst the actual pressure recordings during cystometry in the 37 patients with instability remained identical or very similar in 73%. The results demonstrated the accuracy of cystometry and the consistency of bladder dynamics over the longest period so far reported in these apparently non-progressive disorders.

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Fifty adult males presenting with unheralded single or recurrent urinary tract infections, but without prior urinary symptoms or disorders, were investigated by appropriate urodynamic techniques. Pressure/flow videocystography revealed significant underlying lower urinary tract abnormalities in 40 cases (80%) compared with only 11 (22%) whose abnormalities were also demonstrated by standard intravenous urography or endoscopy. We suggest that videocystography is the most efficient diagnostic procedure for these cases in a specialist unit but recommended the intravenous urodynamogram as a simpler screening test for general use.

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