Enterocutaneous fistula coexisting with enterovesical fistula: a rare complication of ovarian cystectomy

Enterocutaneous fistula is an abnormal communication between the intestine and the skin, while enterovesical fistula is an abnormal communication between the intestine and the bladder. Both are not usual complications of ovarian cystectomy. We present a patient with enterovesical fistula coexisting with enterocutaneous fistula following ovarian cystectomy. She is a 24-year-old lady with background immunosupression who presented to the National Obstetric Fistula Centre, Abakaliki South-East Nigeria with a history fecaluria, pneumaturia and passage of feculent fluid through the skin following ovarian cystectomy. Fistulogram was in keeping with rectovesical fistula. She was repaired in a single stage and made an uneventful recovery. Enterovesical fistula and enterocutaneus fistula are uncommon but possible complications of ovarian cystectomy

The first series of laparoscopic radical cystectomies done in South Africa

Background: Radical cystectomy (RC) with extended lymphadenectomy and urinary diversion remains the standard of care for muscle-invasive urothelial carcinoma. Laparoscopic radical cystectomies (LRC) have been performed at Groote Schuur Hospital (GSH) since 2009. We aimed to audit our data regarding complications and oncological outcome and compare it to data obtained from patients undergoing open radical cystectomy (ORC) by the same surgeon since 2007.Methods: All adult patients who underwent open and laparoscopic RC from 2007 to 2013 have been included in the study. Data on demographics, operative time, intraoperative blood loss, postoperative complications, margin positivity, and lymph nodes was obtained retrospectively by means of folder review.Results: Thirty (30) patients who underwent LRC and 32 who underwent ORC were included in the study. Participants undergoing ORC experienced shorter operative duration (301 minutes versus 382 minutes; p-value < 0.0001), increased blood loss (1376 ml versus 779ml; p-value = 0.0023) and transfusion requirement (2 units versus 0; p-value = 0.071) in contrast to LRC. Postoperative complications were more prevalent in the ORC arm compared to the LRC arm (61% versus 43%). Patients with a past medical history were at higher risk of experiencing postoperative complications (p-value = 0.04; Risk Ratio: 1.6). Margin positivity was comparable between the two arms. A higher number of nodes was sampled by the laparoscopic technique in this study (overall p-value = 0.07).Conclusion: Laparoscopic RC is associated with longer operative times, decreased blood loss, and equivalent oncological outcomes when compared to ORC. Laparoscopic RC is a feasible option in our setting

How to Manage a Dysfunction of the Efferent Segment in Continent Cutaneous Urinary Diversion (Hydraulic Reservoir)? A Retrospective Study of 10 Cases

"Continent cutaneous reservoirs after cystectomy remain an invaluable treatment option for a well-defined subset of indications. The continence mechanism largely determines the treatment success in terms of patient satisfaction and quality of life. Any dysfunction is considered a failure by both patients and surgeons. A retrospective study was made from 2003 to 2013 (13 years) with the aim to characterize the hydraulic valve dysfunction in patients who underwent a cystectomy with continent urinary pouch. A total of ten patients were included in this study. The main age was 44 years. The indications of cystectomy were pelvic tumors (62%); vesico-vaginal fistulas (20%); bladder extrophy (10%); hypospadias (4%) and complicated uretral strictures (4%). An hydraulic continent valve according the Benchekroun process was made for all our patients. After a median follow-up of 36 months; the main related efferent segment complications were fistulas in the top of the valve or ""pinhole fistula"" in 25% of cases; the externalized prolapse of disinserted valve in 25% of cases; and the progressive desinvagination with urinary incontinence in 50% of cases Continent catheterizable urinary diversion remains a treatment option for a well-defined subset of indications. There is little consensus regarding the different options for the efferent segment; which has the greatest influence on patient satisfaction."

Disintegrating Perineal Disease in Patients with Urethral Stricture and HIV Infection: A Review of 12 Cases

The aim of this study was to define disintegrating perineal disease (DPD) and to determine whether the fulminating nature of the condition could be explained by urine and perineal swab microbiology or perineal histology. A retrospective study that included 12 male patients with urethral strictures and DPD was performed. DPD was defined as a chronic; destructive; purulent perineal inflammation with multiple fistulae or sinuses of the perineum; scrotum or penoscrotal area; which continued for more than six weeks despite a patent urethra after direct vision internal urethrotomy (DVIU) or urinary diversion by means of suprapubic cystostomy. The median patient age was 43.5 years (range of 22-68 years). The patients all tested positive for human immunodeficiency virus (HIV) infection. Their mean CD4 count was 340 cells/mm3 (range of 244-1 252 cells/mm3). Histology of the fistula tracts showed non-specific inflammation in 8 patients (66.7); tuberculosis in 2 (16.7); hydradenitis suppurativa in one (8.3); and squamous cell carcinoma in situ with condylomata acuminata in one patient (8.3). DVIU was performed in 10 patients. Patency of the urethra could be achieved in only three patients for more than six weeks. Perineal urethrostomy was completed in three patients after failed DVIU. Ileal conduit urinary diversion and simple cystectomy was carried out in three patients and curing the DPD was accomplished in two. DPD relates to urethral stricture disease in HIV-positive men with secondary infection as the initiating cause; but no predominant microorganism is responsible for the condition. Simple cystectomy with urinary diversion may be the only solution to treating this debilitating disease

Semiquantitative Smoothelin Expression in Detection of Muscle Invasion in Transurethral Resection and Cystectomy Specimens in Cases of Urinary Bladder Carcinoma

Objectives: To examine the usefulness of smoothelin - a new immunohistochemical (IHC) marker that is expressed predominantly in visceral smooth muscle - in recognizing muscularis propria (MP) in transurethral resection (TUR) and matched cystectomy specimens and to compare thepattern of its expression in muscularis mucosae (MM) and MP in radical cystectomy specimens. Methods: IHC staining for smoothelin was performed in 49 cases of urothelial carcinoma removed by radical cystectomy (16 had undergone TUR before the cystectomy). Results: In cystectomy specimens; smoothelin staining in the MP was strong (+3); moderate (+2) and weak (+1) in 49; 44.9and 6.1of cases; respectively; whereas smoothelin positivity in the MM was absent and weak in 77.6and 22.4of cases; respectively. In TUR specimens; smoothelin immunoreactivity was moderate to strong in 68.8and weak in 6.3of cases and all of them proved to have MP invasion in cystectomy specimens. Conclusion: Smoothelin is a useful marker for the detection of MP in TUR specimens. Moderate to strong smoothelin staining of the muscles included in TUR specimens and split by the tumor is a sign of MP invasion. It may be useful in cancer staging and treatment decision making

Clinical Significance of Bacteriuria in Patients with Orthotopic Sigmoid Neobladder after Radical Cystectomy

Objectives: To evaluate the incidence and clinical significance of bacteriuria in patients who underwent sigmoid neobladder substitution after radical cystectomy. Patients and Methods: The study included 149 patients with invasive bladder carcinoma who underwent radical cystectomy and orthotopic sigmoid bladder substitution. Diagnosis of bacteriuria was made by freshly collected midstream urine culture at 3; 6 and 12 months postoperatively. Positive urinary culture was defined as 100 000 colony forming units (CFU)/ml. The data collected were evaluated in correlation to the clinical status of the patients. Results: Overall 466 urine samples from 149 patients were cultured during the follow-up period. Out of these 149 patients; 18 were lost to follow-up and 11 patients developed new stone formation in the neobladder with an incidence of bacteriuria of 91. These 29 patients were excluded from the study. Among the remaining 120 patients; positive urine culture with significant growth of uropathogens was seen in 64; 47and 33at 3; 6 and 12 months; respectively. Two thirds of patients with positive urine cultures were asymptomatic. The commonest uropathogen encountered was E Coli (72) followed by Klebsiella (12). Conclusion: Sigmoid neobladder substitution is associated with a high incidence of bacteriuria. Despite; the spontaneous clearance of bacteriuria over time without antimicrobial manipulation; antimicrobial therapy was needed in some patients; particularly those with a large post-void residual (PVR) urine volume; persistent urosepsis and stone formation in the neobladder

Pathologic Pattern of Invasive Bladder Carcinoma: Impact of Bilharziasis

Objective: To describe the pathologic pattern of invasive bladder carcinoma in cystectomy specimens in relation to bilharziasis. Patients and Methods: Between April 2002 and October 2006; 148 consecutive patients with invasive bladder cancer were subjected to radical cystectomy and orthotopic sigmoid bladder substitution at Al-Azhar Urology Department; Cairo; Egypt. A retrospective computerized data- base analysis of the pathologic features of the cystectomy specimens was done focusing on the impact of bilharziasis on the pathology of bladder carcinoma. The tumor cell type; stage; grade and gross features in addition to lymph node involvement were particularly noted. Results: Bilharzial bladder pathology (lesions or ova) was present in 105 (70.9) of 148 cystectomy specimens. Tumor histology included transitional cell carcinoma (TCC) in 84 (56.7); squamous cell carcinoma (SCC) in 51 (34.5); adenocarcinoma in 9 (6.1) and anaplastic tumor in 4 (2.7) of these specimens. Most tumors associated with bilharziasis were bulky and appeared fungating or ulcerative. The pathologic tumor stage was pT2 in 23; pT3 in 70.9and pT4a involving the prostate or seminal vesicles in 6.1. None of these pT4a tumors were SCC. The tumor grade was described as low grade in 72 (48.6) and high grade in 76 (51.4) specimens. Regional lymph node involvement was detected in 31 (20.9) specimens irrespective of bilharzial infestation. Conclusion: Invasive bladder carcinoma associated with bilharzial pathology is mainly stage pT3; low-grade SCC and commonly appears as an ulcerative; bulky; fungating or verrucous mass. On the other hand; bladder carcinoma not associated with bilharziasis is mainly high-grade TCC and commonly appears as nodular or fungating lesions. Positive surgical margin and lymph node involvement are unrelated to bilharzial infestation

Radical Cystectomy for Locally Advanced Carcinoma of the Bladder in Kano; Nigeria

Objective: Bladder cancer is the second most common genito-urinary malignancy worldwide. The objective of this study was to assess the benefit of radical cystectomy on locally advanced bladder carcinoma in terms of improved quality of life and survival in our environment. Patients and Methods : The records of 58 patients with bladder carcinoma managed at Aminu Kano Teaching Hospital over a 5-year period (May 2000 to April 2005) were reviewed and analysed. Excluded were 28 patients with distant metastatic disease discovered during clinical investigation. Results: Thirty patients (25 males and 5 females) with a mean age of 50.5 years and variable symptoms underwent radical cystectomy for locally advanced carcinoma of the bladder. Urinary drainage was achieved by orthotopic ileal neobladder in 15 patients (50); continent cutaneous reservoir in 11 patients (36.7) and non-continent drainage in 4 patients (13.3). A 40survival was achieved at 6-60 months. Conclusion : Radical cystectomy is a worthwhile procedure in locally advanced carcinoma of the bladder and cure may be achieved in selected patients

The Impact of preservation of the prostatic apex on the urodynamic characteristics in different orthotopic ileal reservoirs

Objective This study was carried out to evaluate the urodynamic characteristics of the Camey II; Kock's and W-configured ileal reservoirs utilized for orthotopic urinary diversion. Patients and Methods Between January 2000 and 2002; 42 male patients prospectively underwent radical cystoprostatectomy for bladder cancer followed by orthotopic urinary diversion at the urology department of Cairo University hospitals. All cases were evaluated clinically; bacteriologically; radiologically and urodynamically including uroflowmetry; medium-fill and voiding enterocystometry and urethral pressure profilometry; which was done in the early and late postoperative period (at 3-6 months and 6-18 months). Patients were divided into four groups: Group I: 11 cases with preservation of the prostatic apex and creation of a W-neobladder. Group II: 11 cases without prostatic apex preservation and creation of a W-shaped ileal pouch. Group III: 12 cases without prostatic apex preservation and creation of a Camey II pouch. Group IV: 8 cases without prostatic apex preservation and creation of a Kock's pouch. Results The patients of Group I had a larger mean neobladder capacity (699 ml) and volume at which the first contraction occurred (315 ml) and a larger amount of residual urine (224 ml) as compared to Group II (511.1; 285 and 77.5 ml; respectively); Group III (375; 200 and 55 ml; respectively) and Group IV (563; 266 and 600 ml; respectively). Also Group I with a preserved prostatic apex had a higher mean intraluminal opening pressure (55 cm H2O) and a higher pressure at maximum flow (62.36 cm H20) as compared to the patients with complete prostatic resection. Conclusion We conclude that the patients with a preserved prostatic apex (Group I) had a statistically significant higher mean residual urine in the early and late postoperative period and a significantly higher mean maximum cystometric capacity in the late postoperative period as compared to those recorded in patients with complete prostatic resection (Groups II; III; IV). A higher incidence of upper tract deterioration was detected in Group I (35) vs. 4.6; 27.8and 12.5in Groups II; III and IV; respectively

Prostatic adenocarcinnoma in cysprostatectomy specimens remolved for bladder tumors in bilharzial patients

Objective To determine the incidence of prostatic adenocarcinoma in bilharzial patients who previously underwent radical cystoprostatectomy for bladder tumors. Patients and Methods From February 1997 to February 1999; 249 male patients with bladder cancer were screened for prostate cancer prior to cystectomy using DRE and total PSA assay; as well as transrectal ultrasound-guided prostatic biopsies. Then the cystoprostatectomy specimens were serially sectioned (every 3 mm) and histologically examined. Results Prostatic adenocarcinoma was detected by ultrasound-guided prostatic needle biopsies in 2 cases; while in 18 it was discovered incidentally after cystoprostatectomy (total 20 patients = 8). Gleason score was 6 in 16 patients; 7 in 3 patients and 8 in the remaining patient. Perineural lymphatic permeation was observed in 4 cases and extracapsular extension in one. Conclusion Compared to previous reports on non-bilharzial patients; the incidence of prostate cancer in the cystoprostatectomy specimens of bilharzial patients was low; and the tumors were clinically insignificant in most of the cases