How to avoid clean intermittent catheterization in men with ileal bladder substitution

PURPOSE: In male patients with ileal bladder substitute we ascertained the likelihood of spontaneous voiding failure, the corrective procedures required and the eventual outcomes. MATERIALS AND METHODS: Following cystectomy and ileal bladder substitution for urothelial cancer between April 1985 and September 2002 male patients were identified and analyzed from the prospective departmental database. Four patients underwent ileum conduit conversion following urethral recurrence or pouch necrosis and were excluded from study. Funnel-shaped outlets were avoided during bladder substitute surgery after the first 4 patients with this configuration experienced voiding failure and required corrective procedures. Only patients with a minimum 5-year followup were assessed for voiding failure, corrective procedures and final outcomes. RESULTS: Of 354 patients with a median age of 65 years (range 36 to 84) treated with bladder substitute 180 (51%) were alive at 5 years. All 180 of these patients spontaneously voided within 3 months of surgery. During this 5-year observation period 22 (12%) patients experienced voiding problems requiring de-obstructive procedures. Following intervention 177 (98%) patients were spontaneously voiding by 5 years. Of 237 patients 77 (32%) were alive at 10 years. Of these 77 patients followed for another 5 years 10 (13%) had similar voiding problems requiring de-obstructive procedures. Subsequently 74 (96%) were voiding spontaneously by 10 years. CONCLUSIONS: Patients often fail to void spontaneously after ileal bladder substitution. However, if a funnel-shaped outlet is avoided and de-obstructive surgery is appropriately implemented, excellent long-term results are seen with spontaneous voiding and clean intermittent catheterization can be avoided.

How to Tango: a manual for implementing Spine Tango

The generic approach of the Spine Tango documentation system, which uses web-based technologies, is a necessity for reaching a maximum number of participants. This, in turn, reduces the potential for customising the Tango according to the individual needs of each user. However, a number of possibilities still exist for tailoring the data collection processes to the user's own hospital workflow. One can choose between a purely paper-based set-up (with in-house scanning, data punching or mailing of forms to the data centre at the University of Bern) and completely paper-free online data entry. Many users work in a hybrid mode with online entry of surgical data and paper-based recording of the patients' perspectives using the Core Outcome Measures Index (COMI) questionnaires. Preoperatively, patients can complete their questionnaires in the outpatient clinic at the time of taking the decision about surgery or simply at the time of hospitalisation. Postoperative administration of patient data can involve questionnaire completion in the outpatient clinic, the handing over the forms at the time of discharge for their mailing back to the hospital later, sending out of questionnaires by post with a stamped addressed envelope for their return or, in exceptional circumstances, conducting telephone interviews. Eurospine encourages documentation of patient-based information before the hospitalisation period and surgeon-based information both before and during hospitalisation; both patient and surgeon data should be acquired for at least one follow-up, at a minimum of three to six months after surgery. In addition, all complications that occur after discharge, and their consequences should be recorded.

How to be naive

The transcription factor KLF2 directs expression of receptors involved in trafficking of naive T cells. In this issue of Immunity, Weinreich et al. (2009) demonstrate that KLF2 additionally represses IL-4 production, which otherwise induces CXCR3 expression.

Septic shock resuscitation: what goals and how to achieve them?

The need to achieve adequate tissue oxygen delivery early in patients with septic shock is well established. However, it is less well recognized that tissue hypoperfusion can exist despite normalization of systemic hemodynamics. Efforts to resuscitate septic patients until adequate tissue perfusion has been achieved can potentially improve outcome. In a multicenter study, 130 patients with septic shock were resuscitated within 12 hours of diagnosis using a protocol including goals for mean arterial and pulmonary artery occluded pressures, urinary output, arterial pH, and hemoglobin goals. They were then randomly assigned to further resuscitation with either a cardiac index (>or= 3 l/minute per m2) or a gastric mucosal pH (>or= 7.32) target. The intensive care unit length of stay and 28-day mortality did not differ between groups, but more patients in the cardiac index group were in the target range, both at baseline and after resuscitation, as compared with the gastric mucosal pH group. In contrast to cardiac index, gastric mucosal pH at baseline and at 24 and 48 hours predicted mortality. Whether other targets for the chosen variables, or different and--in particular--earlier resuscitation efforts would have favored one group cannot be concluded from the data provided.