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OBJECTIVE To review the long-term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6-year period at one tertiary referral centre. PATIENTS AND METHODS Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow-up, complications and revision procedures, and the most recent uroflowmetry results. RESULTS There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant-related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s. CONCLUSION In young women with retention, for whom there is still no alternative to lifelong self-catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.

The case of an 81-year-old man with a known 5.2 cm abdominal aortic aneurysm (AAA) and transitional cell carcinoma of the bladder who presented to the emergency department in painful clot retention is described. Approximately 5 h after starting bladder irrigation he developed a sudden onset of severe abdominal pain radiating to his back. Urgent CT scan (AAA protocol) revealed a rupture of the lower pole calyx of his right kidney and a stable aneurysm. Bladder irrigation was stopped and the patient settled with a catheter and simple analgesia. Given his significant co-morbidities, it was felt that surgical intervention for the underlying malignancy was inappropriate and the patient was discharged home. At last outpatient review, his renal function was at its baseline and he was suffering no ill-effects from the ruptured kidney.

The application of novel technology and innovative surgical techniques has contributed greatly to the advance of endourology over the past two decades. Key developments include endoscopic access to the urinary tract and advances in intraand extra-corporeal stone fragmentation techniques. Of these techniques, laser technology has also been applied to other branches of urology including prostate surgery, ablation of urothelial tumors, and treating urinary strictures. The safe introduction of this potentially hazardous technology has required defining stringent safety guidelines, which encompass protection of both the patient and the user. In this chapter, physics of laser is discussed, along with the review of its application in treating stones.

The use of antibiotic prophylaxis is an accepted and widely practiced feature of modern surgery. The prevention and control of infection is a priority in healthcare worldwide, and the emergence of antibiotic resistance is a global phenomenon. Hence, rational use of antibiotics is essential. We discuss the guidelines published with regard to endourologic procedures and review the limited evidence currently available. There should be subclassification of endourologic procedures based on infection risk to guide sensible use of antibiotics before surgery.

Study Type – Aetiology (case series) Level of Evidence 4 OBJECTIVE To examine brain responses to bladder filling in young women with Fowler’s syndrome (FS, a sphincter abnormality manifested by impaired voiding and bladder sensation), treated with sacral neuromodulation (SNM). PATIENTS AND METHODS Six women, aged 18–39 years with FS underwent functional brain magnetic resonance imaging (fMRI) immediately after SNM and when untreated (baseline). Data were collected at four sessions: after SNM with an empty and a full bladder, and at baseline with an empty and a full bladder. In each session, 280 whole-brain scans were acquired while repeatedly infusing and withdrawing 50 mL of saline, using push-buttons to report changing desire to void. Data were analysed using Statistical Parametric Mapping. RESULTS At baseline with an empty bladder, extensive responses (contrast = infusion–withdrawal) were almost exclusively negative (‘deactivations’), e.g. in the right insula, seat of visceral sensation. Increased bladder volume and/or SNM treatment reduced deactivations and strengthened normal (positive) responses, e.g. in the periaqueductal grey (PAG) terminus of ascending spinal afferents. At baseline, there was significant correlation of brain responses with maximum urethral closure pressure. CONCLUSION These data show that brain responses to bladder filling are abnormal in FS. The explanation for this that best explains the evidence is that the primary abnormality is an overactive urethra that generates abnormally strong inhibitory afferent signals, so effectively blocking bladder afferent activity at the sacral level and deactivating the PAG and higher centres, with consequent loss of bladder sensation and ability to void. Apparently, a normal mechanism for suppression of incontinence involving the striated urethral sphincter becomes exaggerated in FS and prevents voiding. SNM seems to act at the sacral level, by blocking inhibition by urethral afferents.

Epidemiology, aetiology, diagnosis and management.

Introduction Retrograde ejaculation is not a recognized complication of ureteric reimplantation surgery. We describe this unusual complication in a 25-year-old man, with no other cause for his ejaculatory dysfunction. Case presentation A 25-year-old Caucasian man presented with left hydronephrosis ascribed to a megaureter. Following open reimplantation of the ureter, the patient developed retrograde ejaculation that did not respond to medical therapy. Conclusion The key result reported here is that retrograde ejaculation is a possible complication of open pelvic surgery, for which patients should receive counselling. This is relevant for both urologists and general physicians who consult relatively young men with ejaculatory difficulties.

The age of peak incidence for stone disease is 20-40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions for stone removal in people with asymptomatic kidney stones? What are the effects of interventions for the removal of symptomatic renal stones? What are the effects of interventions to remove symptomatic ureteric stones? What are the effects of interventions for the management of acute renal colic? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodic drugs, extracorporeal shockwave lithotripsy, intravenous fluids, NSAIDs, opioids, oral fluids, percutaneous nephrolithotomy, and ureteroscopy.

To review the management of female urethral diverticular tumours, and rationalize treatment protocols.A literature search through Medline, Psychoinfo, EMBASE and the Cochrane library from 1951 was performed for all reports and series of urethral diverticular tumours.A total of one male patient and 75 female patients were reported, with data on demographics, presentation, diagnosis, treatment modalities, recurrence rates and mortality. There is considerable variation in the method of reporting outcomes, and heterogeneity in treatment methods.There appears to be no current consensus in the management of these rare tumours. There is an urgent need to establish an international registry of rare tumours to help formulate guidelines on management of such tumours. We propose a management algorithm based on the evidence gathered from review of the published literature.

Purpose of review Extracorporeal shock wave lithotripsy has been used for over 2 decades, but its application in the acute setting remains under review. With continuing refinements to the technology, it is timely to review its efficacy in the emergency setting. Recent findings The procedure has an overall low morbidity and is generally well tolerated. Success rates of 70–80% are reported in a number of studies, with relatively low complication rates. Although much attention has been given to the improvements in the outcome of ureteroscopic stone clearance, the benefits of a noninvasive procedure which does not require general anaesthesia may be appealing and indeed preferable for many patients. Summary This should remain a valid alternative treatment option offered to patients, and its provision may be restricted by resource availability rather than clinical evidence. Centres should be identified that can offer an emergency extracorporeal shock wave lithotripsy service and patients informed of outcome data from such centres.

The use of botulinum toxin in paediatric urology has become increasingly widespread during recent years; however, the evidence base for its clinical use has been from adult urology centres and trials. The mechanism of action of this potent neurotoxin is discussed and evidence for its efficacy and safety is reviewed in both the adult and paediatric literature. Second, an electronic literature search was performed using the keywords paediatric urology, botulinum toxin, bladder, sphincter, and voiding dysfunction (excluding abstracts, letters and case reports). A total of 225 children in 10 peer-reviewed publications were evaluated with 165 paediatric patients with neurogenic overactivity (6 studies), 21 patients with idiopathic overactivity (1 study) and 39 patients with voiding dysfunction (3 studies). Specifically, we discuss the main indications of intravesical injections for detrusor overactivity and of intrasphincteric injections for refractory voiding dysfunctions in the paediatric population.

A 45 year old Korean man presented with a two week history of haemoptysis, chest pain, fever and malaise. He was a nonsmoker with no significant past medical history. On examination he was pyrexial (38.5 °C) with right-sided crepitations of the chest. Blood tests revealed a leukocytosis (14.0×10) with a predominance of neutrophils (9.4×10), and an elevated Creactive protein (120 mg/L). Urinary dipstick revealed 3+ leukocytes and 2+ blood. Chest radiography showed patchy right middle lobe consolidation. Initial sputum culture was reported as a growth of respiratory commensal organisms only, with no evidence of acid-fast bacilli. After 3 days of empirical treatment with intravenous cephalosporins, his clinical condition deteriorated and he now described perineal pain. Repeat auscultation revealed diffuse bilateral chest crepitations and chest radiograph now showed multiple cavitating lesions (Fig. 1). Trans-thoracic echocardiography did not reveal any evidence of endocarditis. The prostate was mildly tender on digital rectal

Urinary retention in women is a diagnostic and therapeutic challenge to urologists and to all involved in the treatment of the condition. The patients referred to a single institution with this condition over a 4-year period were audited and the data are presented. The importance of Fowler's syndrome is described, as is the value of sacral nerve stimulation in this condition. In another paper, authors from France present evidence of occult dysautonomia in Fowler's syndrome. OBJECTIVE To report the experience of the last 4 years from a centre to which women with voiding difficulties and urinary retention were referred nationally, describing what investigations were helpful in making a diagnosis and the management strategies used PATIENTS AND METHODS Women with voiding difficulties and urinary retention remain a diagnostic and management challenge, and those with no anatomical or neurological basis for their symptoms may be dismissed, assuming that their retention has a psychogenic basis. The finding of an electromyographic (EMG) abnormality of the striated urethral sphincter explaining their disorder (Fowler's syndrome) has led to the referral of women for consideration of that diagnosis. Thus we audited the referrals to the centre over a 4-year period of such women. RESULTS In all, 247 women (mean age 35 years) with complete (42%) or partial retention (58%) were referred; 175 (71%) had urethral pressure profilometry, 141 (57%) had a transvaginal ultrasonographic measurement of the sphincter volume, and 95 (39%) had sphincter EMG. The mean maximum urethral closure pressure difference between patients with an EMG abnormality (101.5 cmH2O) and the patients with known other causes of voiding dysfunction (66.2 cmH2O) was 35.3 cmH2O (P

The central control of the bladder is a complex, multilevel process. Recent advances in functional brain imaging have allowed research into this control in humans. This article reviews the functional imaging studies published to date and discusses the regions of the brain that have been implicated in the central control of continence. Brain regions that have been implicated include the pons (pontine micturition center, PMC), periaqueductal gray (PAG), thalamus, insula, anterior cingulate gyrus, and prefrontal cortices. The PMC and the PAG are thought to be key in the supraspinal control of continence and micturition. Higher centers such as the insula, anterior cingulate gyrus, and prefrontal regions are probably involved in the modulation of this control and cognition of bladder sensations, and in the case of the insula and anterior cingulate, modulation of autonomic function. Further work should aim to examine how the regions interact to achieve urinary continence.

We used hand-assisted laparoscopy to remove the nonfunctioning left moiety of a horseshoe kidney. The handport was a useful adjunct and can be helpful in training surgeons developing their laparoscopic skills.

Sacral nerve stimulation (neuromodulation) can restore bladder sensation and the ability to void in women with urinary retention due to sphincter overactivity (Fowler's syndrome). Modulation of central afferent activity is considered critical to this therapeutic effect but the neural mechanisms are poorly understood. Therefore, we undertook a functional brain imaging study to determine how neuromodulation acts on brain centers involved in the representation and control of bladder function.Eight patients with Fowler's syndrome and 8 healthy controls underwent brain imaging with positron emission tomography to identify regions of brain activity relating to the perception of bladder fullness and their modulation by sacral nerve stimulation.In healthy controls bladder fullness enhanced activity in brainstem (midbrain) and limbic cortical regions. Women with urinary retention showed no significant brainstem activity but did show enhanced limbic cortical activity when the bladder was full in the absence of neuromodulation. Neuromodulation restored a normal pattern of midbrain activity and decreased cortical activity in this group.Our study provides novel neuroimaging evidence for the existence of abnormal interaction between brainstem and cortical centers in women with urinary retention. Furthermore, we have been able to show evidence that the therapeutic effect of sacral neuromodulation is achieved through restoration of activity associated with brainstem autoregulation and attenuation of cingulate activity.

The majority of patients with multiple sclerosis (MS) develop troublesome lower urinary tract symptoms (LUTS). Anecdotal reports suggest that cannabis may alleviate LUTS, and cannabinoid receptors in the bladder and nervous system are potential pharmacological targets. In an open trial we evaluated the safety, tolerability, dose range, and efficacy of two whole-plant extracts of Cannabis sativa in patients with advanced MS and refractory LUTS. Patients took extracts containing delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD; 2.5 mg of each per spray) for eight weeks followed by THC-only (2.5 mg THC per spray) for a further eight weeks, and then into a long-term extension. Assessments included urinary frequency and volume charts, incontinence pad weights, cystometry and visual analogue scales for secondary troublesome symptoms. Twenty-one patients were recruited and data from 15 were evaluated. Urinary urgency, the number and volume of incontinence episodes, frequency and nocturia all decreased significantly following treatment (PB/0.05, Wilcoxon’s signed rank test). However, daily total voided, catheterized and urinary incontinence pad weights also decreased significantly on both extracts. Patient self-assessment of pain, spasticity and quality of sleep improved significantly (PB/0.05, Wilcoxon’s signed rank test) with pain improvement continuing up to median of 35 weeks. There were few troublesome side effects, suggesting that cannabis-based medicinal extracts are a safe and effective treatment for urinary and other problems in patients with advanced MS.

We investigated the action of sacral neuromodulation in restoring voiding function in women with urinary retention attributable to sphincter overactivity (Fowler's syndrome).We recruited women within retention who were able to void following neuromodulation by temporary test stimulation or a permanent implant. Urethral pressure profiles, cystometry and sphincter electromyography were performed before and after neuromodulation.A total of 30 women 19 to 52 years old were recruited, including 21 with a permanent implant and 9 undergoing temporary stimulation. Mean maximum urethral closure pressure was elevated compared to expected pressure and it did not change significantly after neuromodulation. The electromyographic abnormality persisted during neuromodulation and voiding was often done with an interrupted flow. There was a slight increase in detrusor contractility.This evidence suggests that neuromodulation does not restore voiding in these patients by a direct relaxant effect on the sphincter. The modest increase in detrusor pressure appears to be sufficient to overcome the resistance of the overactive sphincter.

We assessed the tolerability, safety and efficacy of sildenafil for the treatment of women with sexual dysfunction secondary to multiple sclerosis, as well as the role of somatosensory evoked potential neurophysiological testing.We performed a double-blind, randomized, placebo controlled, crossover study investigating the effects of sildenafil in women with multiple sclerosis and sexual dysfunction. Assessments were done by validated questionnaires. Pudendal and tibial evoked potentials were also recorded.A total of 19 women completed the 2 arms of the double-blind phase and 12 completed the optional open label extension phase. Statistically significant improvement following sildenafil was only reported in the lubrication domain of sexual function during the double-blind phase. There was no overall change in quality of life after sildenafil. There was a significant correlation between the latency of tibial and pudendal evoked potentials.Sildenafil only appeared to produce limited benefit in certain individuals with female sexual dysfunction. Some measure of the extent of neurological deficit in these patients could be ascertained from the latency of tibial evoked potentials, which correlated with pudendal evoked potentials. However, it could not predict the extent of sexual dysfunction. Sildenafil is unlikely to help all patients with neurogenic female sexual dysfunction.

Purpose of review Several aspects of voiding dysfunction in women remain under investigation, including standardization of the diagnosis and management of bladder outflow obstruction. This article describes a specific cause of urinary retention in young women, associated with a failure of urethral sphincter relaxation, and a treatment option that can restore voiding in this group of patients - sacral nerve electrical stimulation therapy. Recently there have been advances in the stimulator implantation technique, as well as in our appreciation of its mechanism of action.Recent findings Advances include the use of ancillary investigations such as urethral function tests as well as better understanding of the clinical profile of these patients. Improvements in the surgical technique include better methods of lead fixation and a less invasive surgical approach. Research suggests the action of neuromodulation is on the afferent pathway, though it remains to be shown whether this is at a spinal or supraspinal level. It is likely that sacral nerve stimulation has an indirect modulatory effect on detrusor contractility rather than a direct effect on the sphincter.Summary Experience of sacral nerve stimulation has increased over the past few years, and its application is expanding to other clinical domains. This knowledge has helped improve the therapy, which is particularly effective in the treatment of women with urinary retention. Although how it works is still not fully understood, this is something that is being addressed by ongoing research.

Surgical excision of osteochondromata occurring at the lateral aspect of the distal tibia is hampered by the difficult access to this area. Current techniques use an anterior approach, but this makes access to the posterior aspect of the tibia difficult. The authors report on 2 cases in which removal, and subsequent replacement of distal fibula and fixation with a semitubular plate, allowed complete excision of a distal tibial osteochondroma and satisfactory outcomes. This procedure provides an alternative technique to the anterior approach previously described. The literature appears to contain no similar previous reports.

The fundamental strategy in treating multiple sclerosis patients with unstable bladders involves a combination of suppressing urgency and ensuring effective urinary drainage. Anti-cholinergics remain the first-line treatment, but alternative therapies are undergoing clinical trials. With a range of new pro-erectile oral medications available, interest has grown in treatment of multiple sclerosis-related erectile failure. Female sexual dysfunction is also now gaining some attention, with new classification criteria and methods for assessing and treating these patients.

A patient was referred to our department for management of a renal pelvis “stone.” During percutaneous nephrolithotomy, the stone was discovered to have formed around a Hem-o-lok® clip, retained from a previous surgical procedure. As with other surgical foreign bodies, the Hem-o-lok acts as a nidus for stone formation if in prolonged contact with urine. It is radiolucent and therefore crucial to apply with caution in proximity to the urinary tract.

[1]. Specifically, on page 885, the authors' state ‘The present study showed that the use of pericapsular injection with 1% lignocaine around the prostate before biopsy significantly reduced the subjective intensity of pain during the procedure. One other published study investigated the use of local anaesthetic injection before TRUS-guided biopsy; Nash