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11/35. Anastomotic obstruction after stapled enteroanastomosis.

    We have recently treated two cases of anastomotic obstruction after side-to-side stapled enteroanastomosis. Complete obstruction of a stapled small-bowel anastomosis has not been reported to our knowledge. The mechanism of the obstruction appears to be the healing together of the cut edges of viable bowel beyond the inverted stapled lines. An alternative method of constructing the functional end-to-end enteroanastomosis that is offered is intended to prevent the occurrence of postoperative anastomotic obstruction.
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12/35. Small-bowel obstruction caused by a long-term indwelling urinary catheter.

    The first known case report of a small-bowel obstruction caused by a long-term indwelling Foley catheter is presented. The balloon of the catheter passed into and obstructed the lumen of the distal ileum through a vesicoenteric fistula created by chronic irritation. With the exception of recurrent urinary-tract infections, complications of urinary catheters are rare. The patient presented a diagnostic dilemma that was solved with a preoperative computed tomographic scan.
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13/35. Upper urinary tract deterioration after implantation of artificial urinary sphincter.

    The preoperative urodynamic evaluations of twenty patients with myelomeningocele who had had artificial sphincter implantation because of urinary incontinence were reviewed. Four patients developed hydronephrosis and severe impairment of renal function between two and six years after implantation of the artificial sphincter. The condition was partly reversible after removal of the artificial sphincter. The urodynamic evaluation prior to implantation revealed in the four mentioned patients compared to the 16 patients with normal upper urinary tract, a tendency to lower bladder compliance, lower bladder capacity and more severe detrusor hyperreflexia, but it was not possible to make a clear discrimination between the two groups. attention is drawn to this unfortunate combination of effects after artificial sphincter implantation. Periodic control of the upper urinary tract by urography is recommended.
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14/35. Is evaluation of the right colon necessary prior to cecocystoplasty?

    Use of the ileocecal bowel segment in urological surgery has become more widespread. Thorough preoperative evaluation of the bowel is seldom performed. A case is presented in which the intraoperative finding of numerous cecal polyps led to abortion of a planned cecocystoplasty. The literature on fecal occult blood testing and screening methods for colorectal neoplasia was reviewed. patients are classified into 2 categories, average risk and high risk, according to the relative risk for colorectal neoplasia. The data suggest that the fecal occult blood test, if properly performed, is an adequate screening tool for average risk patients. However, because of the high rate of false negative results this test is inadequate for evaluation of high risk patients. It is recommended that such patients should undergo preoperative screening colonoscopy regardless of the fecal occult blood test result.
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15/35. Dural laceration occurring with burst fractures and associated laminar fractures.

    The cases of sixty patients in whom a burst fracture of a thoracic or lumbar vertebral body had been treated with posterior instrumentation and arthrodesis less than two weeks after the injury were retrospectively reviewed. Thirty of the patients had an associated laminar fracture. Eleven of the thirty, all of whom had a lumbar fracture and a preoperative neurological deficit, were noted at operation to have dural laceration. In four of the patients who had dural laceration, neural elements were entrapped between the fragments from the laminar fracture. None of the remaining thirty patients who did not have a laminar fracture had dural laceration (p = 0.0002). Univariate and multivariate statistical analysis revealed no significant association of the dural laceration with the patients' age or sex, or with the radiographic characteristics of the spine. There was a significant association between dural laceration and neurological deficit (p = 0.0001). In our series, the presence of a preoperative neurological deficit in a patient who had a burst fracture and an associated laminar fracture was a sensitive (100 per cent) and specific (74 per cent) predictor of dural laceration. The presence of this fracture pattern and an associated neurological deficit also predicted a risk of dural laceration with entrapped neural elements. This information may influence decisions as to whether an anterior or a posterior surgical approach should be used in such patients.
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16/35. urinary retention due to idiopathic megacolon.

    A 58-year-old man with neurogenic bladder dysfunction was hospitalized with chief complaints of urinary retention and abdominal distention. He had been treated for neurogenic bladder due to cerebral infarction for 3 years. The pelvic CT scan and excretory urogram revealed an obstruction of the neck of the bladder due to an abundant stool, which was found to have resulted from adult idiopathic megacolon. A permanent colostomy with sigmoid resection was established. The postoperative urodynamic examination demonstrated improvement of micturition.
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17/35. Division of the external urethral sphincter in the treatment of the paraplegic bladder: a preliminary report on a new procedure.

    Division or resection of the external sphincter is a new operation designed to relieve retention of urine (or a high residue) in patients with an open bladder-neck and a narrow, rigid external sphincter area and in whom subarachnoid alcohol block, pudendal neurectomy or a bladder-neck resection have failed to help. The operation converts a chronic retention to an easily expressible bladder. Ten patients are reported. The operation technique is described. During the post-operative period care is necessary in preventing or dealing with clot-retention and with severe infection due to absorption of organisms in the urethra. The operation should not be attempted in patients with grossly dilated upper urinary tracts and in those with uncontrollable infection. The eight surviving patients have been spared the catheter life and, possibly, subsequent damage to the upper urinary tract.
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18/35. The complications of urinary tract reconstruction.

    We reviewed 56 patients who underwent urinary tract reconstruction between 1977 and 1984. There were 27 total complications in this group, which ranged from straightforward undiversion to total bladder replacement. Complications were divided into preoperative planning errors and errors of surgical technique. The patients at greatest risk seemed to be those with compromised renal function who previously had undergone diversion for severe obstructive uropathic conditions and those in whom bowel segment was an integral part of the reconstruction. patients with adequate renal function in whom urothelium alone was used in the reconstruction experienced the fewest complications.
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19/35. The impact of the artificial urinary sphincter in the neurogenic bladder on the upper urinary tracts.

    The charts and x-rays of 120 neurogenic bladder patients who underwent artificial sphincter implantation for treatment of urinary incontinence between 1973 and 1984 were reviewed retrospectively. patients were followed for 3 to 130 months (average 36.8 months). The upper urinary tracts remained unchanged in 108 patients (90 per cent). Renal growth in children was undisturbed. Transient hydroureteronephrosis occurred in 8 patients (6.7 per cent) and progressive hydroureteronephrosis occurred in 4 (3.3 per cent). A total of 26 patients with vesicoureteral reflux (39 ureters) underwent ureteral reimplantation. Our results indicate that implantation of the artificial urinary sphincter in neurogenic bladder patients has minimal adverse impact on the upper urinary tracts, followup should be long-term and should include an IVP, outflow obstruction should be eliminated preoperatively by means of external sphincterotomy in male patients and bladder flap urethroplasty in female patients, similarly, adequate emptying of the bladder always must be assured during followup, if hydroureteronephrosis is detected early appropriate treatment can restore normal upper tracts, the presence of previously damaged upper tracts without evidence of obstruction is not a contraindication for artificial sphincter implantation and an antireflux operation in combination with artificial sphincter implantation is feasible.
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20/35. The manifestation and management of late urological complications in renal transplant recipients: use of the urological armamentarium.

    The incidence of urological complications in renal transplant patients is well documented. The majority of these complications occur in the early postoperative period; late occurrences (more than 3 months) are much less common. We have had experience with 7 patients who presented with late complications 3 months to 7 years after transplantation: ureteral obstruction occurred in 4 patients, ureteral disruption or laceration in 2 and neurogenic bladder with hydronephrosis in 1. Management of these patients has been varied and has included cystoscopic stent placement, Boari flap, ureteropyelostomy, ureteroneocystostomy, bladder augmentation and urinary undiversion. Grafts have been salvaged in 6 of 7 patients. Transplant patients who present with late urological complications can be challenging. However, the potential for intervention and graft salvage is excellent.
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