Simplified Indiana pouch with multiple teniamyotomies.

OBJECTIVES: To describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouch with multiple teniamyotomies without detubularization and reconfiguration. METHODS: From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique using teniamyotomies without detubularization and reconfiguration. The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. The efferent tract of the reservoir was prepared using the appendix. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed. RESULTS: The mean follow-up was 3 years (range 1 to 5). Continence was excellent for 40 patients (91%); in 4 patients (9%), daytime incontinence was reported. The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). Long-term complications occurred in 15 patients (34%), with a mean onset of 13.4 months postoperatively. CONCLUSIONS: Our experience showed that a modified Indiana pouch with multiple teniamyotomies has a good capacity with low internal pressure and good continence. Thus, even with the comparable results of other continent pouch models, our modified Indiana pouch is a valid alternative because of its simplicity to perform.

Benign prostatic hyperplasia: correlations between receptor density and binding affinity of alpha(1)-adrenoceptors and several clinical parameters.

The aim of the study was to determine whether relations do exist between the concentration and activity of alpha(1)-adrenoceptors, both inside the prostatic adenoma and the periurethral zone corresponding to the bladder neck, and clinical and biological parameters such as symptoms, evaluated by the American Urological Association (AUA) score, age, weight of the prostate, PSA, and the flow rate. Twenty patients with symptomatic benign prostatic hyperplasia were selected for an open prostatectomy. One gram of tissue was dissected from inside the adenoma and 1 g from the periurethral zone corresponding to the bladder neck. The alpha(1)-adrenoceptors were evaluated for the apparent dissociation constant (K(d)) and the maximal number of binding sites (B(max)). A correlation seems to exist between receptor density inside the adenoma and the bladder neck and an inverse correlation between receptor density and the AUA total symptoms score. Finally, a highly significant difference was found in patients with an AUA score of <15 or >15. No relationship was found between receptor binding affinity and the considered clinical parameters.

Sensitive detection of transitional cell carcinoma of the bladder by microsatellite analysis of cells exfoliated in urine.

Transitional cell carcinoma (TCC) is the most common bladder tumor. Urine cytology can identify most high-grade tumors but sensitivity is lower if one includes lesions of all grades. Microsatellite marker alterations have been found in many tumor types including bladder cancer and have been used to detect cancer cells in body fluids including urine. The aim of our study is to further evaluate feasibility and sensitivity of microsatellite analysis to detect bladder cancer cells in urine. We studied 55 individuals: 21 with symptoms suggestive of bladder cancer, 23 patients with previous history of TCC and 11 healthy subjects. Genomic DNA was extracted from blood lymphocytes, urine sediment, bladder washings and tumor or normal bladder mucosa. Twenty highly informative microsatellite markers were analyzed for loss of heterozigosity (LOH) and microsatellite instability (MIN) by polymerase chain reaction. Microsatellite analysis of urine identified 33 of 34 (97%) patients with either primary or tumor recurrence, whereas urine cytology identified 27 of 34 (79%) patients (p = 0.0001). Detection of microsatellite abnormalities improved the sensitivity of detecting low-grade and/or stage bladder tumor: from 75-95% for grades G1-G2 and from 75-100% for pTis-pTa tumors. Bladder washings from 25 patients were also analyzed, and in all cases results were identical to those obtained from voided urine. None of the 16 patients without evidence of TCC showed LOH and/or MIN in urine samples or bladder washings. Interestingly, in a patient with persistent bladder mucosa abnormalities, microsatellite alterations were demonstrated 8 months before the histopathologic diagnosis of tumor recurrence. These results further indicate that microsatellite marker analysis is more sensitive than conventional urine cytology in detecting bladder cancer cells in urine and represents a potential clinical tool for monitoring patients with low-grade/stage TCC.

Long-term behavior of secretory immunity in ileocecal and ileal orthotopic neobladders.

OBJECTIVE: To compare secretory immunity in cecal and ileal orthotopic neobladders, and to detect its permanence over time. PATIENTS AND METHODS: IgA was studied in the urine of 33 patients with ileocecourethrostomy (ICUS) and 13 patients with ileal reservoir (IR). The mean follow-up was 55 months. Results were compared in terms of the type of operation, a healthy control group, and the time since surgery. RESULTS: Urinary IgA levels were significantly higher in ICUS and IR patients than in normal controls. No significant differences in IgA concentrations were detected in patients with different reservoirs and with regard to time. CONCLUSION: Both the reservoirs maintain the function of producing IgA. In particular no differences were detected over time and urine could be a permanent antigenic stimulus. IgA could be considered an adjunctive factor for upper urinary tract protection. For this reason we prefer to use a simple, indirect antireflux mechanism, thus avoiding direct manipulation of the uretero-intestinal anastomosis.

Tumor specific modulation of KU70/80 DNA binding activity in breast and bladder human tumor biopsies.

The Ku70/80 heterodimer is the regulatory subunit of the DNA-dependent protein kinase (DNA-PK) and its DNA-binding activity mediates DNA double-strand breaks repair. Although Ku80 was recently proposed as a caretaker gene involved in the control of genome integrity, no data are available on Ku70/80 DNA-binding activity in human tumors. Heterodimer DNA-binding activity and protein expression were assayed by electrophoretic-mobility-shift-assay (EMSA) and Western blot analysis, in nuclear and cytoplasmic extracts from eight breast, seven bladder primary tumors and three metastatic nodes from breast cancers. Corresponding normal tissues of the same patients were used as controls. Ten out of 15 tumors showed nuclear Ku-binding activity 3-10 times higher than in the normal tissues, irrespective of bladder or breast origin. Conversely, in 5/15 primary tumors and in all the metastatic nodes analysed, nuclear Ku-activity was 1.5-4.5-fold lower than in the corresponding normal tissues. Cytoplasmic heterodimer activity significantly differed between tumor and normal tissues, displaying a 2-10-fold increase in neoplastic tissues. Three different patterns combining both Ku expression and activity with tumor characteristics were identified. In low aggressive breast tumors p70/p80 proteins were expressed in tumor but not in normal tissues. The heterodimer binding-activity matched the protein levels. In non-invasive bladder carcinomas no significant differences in protein expression between tumor and the corresponding normal tissues were found, however heterodimer binding-activity was increased in tumor samples. In breast and bladder tumors, at the advanced stage and in node metastases, the binding activity was strongly reduced in tumor biopsies, however no differences were demonstrated between normal and tumor protein levels. Our results suggest a different modulation of Ku70/80 DNA-binding activity in human neoplastic tissues, possibly related to tumor progression. Findings provide further data on tissue-specific protein expression and post-translational regulation of heterodimer activity.

Acid-base and electrolyte balance in urinary intestinal orthotopic reservoir: ileocecal neobladder compared with ileal neobladder.

OBJECTIVES: To compare acid-base and electrolyte balance in ileocecal and ileal neobladders. METHODS: Acid-base and electrolyte balance were studied in 45 patients with an ileocecourethrostomy and 18 patients with an ileal reservoir. The mean follow-up was 51 months. Results were compared with regard to both the type of operation and the time since surgery. RESULTS: No significant differences were found with regard to either the type of operation or the length of follow-up. A preserved renal function is important in maintaining a healthy status. CONCLUSIONS: The use of 35 to 40 cm of ileum or 10 cm of cecum with the ileocecal junction seems to be safe even after a long follow-up. The length rather than the kind of bowel used for bladder replacement appears to be important in safeguarding hydroelectrolyte and acid-base homeostasis. This is particularly true in the presence of preserved renal function.

Haemodynamic changes detected during open prostatectomy and transurethral resection for benign prostatic hyperplasia.

To detect possible intraoperative haemodynamic differences, 60 patients undergoing transurethral (n = 18) or open prostatectomy (n = 42) for benign prostatic hyperplasia were evaluated. The same type of general anaesthesia was used in the two groups. Data, including temperature and cardiac output, were collected at five standard times during the procedures. No significant differences were found between the two groups. However, in all patients, irrespective of the operation, significant decreases in cardiac output and increases in systemic resistance occurred during surgery. Body temperature showed a mild, insignificant decrease, which may play a role in determining the mild haemodynamic derangement observed in all patients. Our patients subjected to open prostatectomy and transurethral resection presented the same kind of haemodynamic derangement, with no significant differences. Therefore it seems unlikely that the kind of surgery could play a relevant role in the late mortality rate of these patients.

Xylose absorption and metabolic status in urinary intestinal orthotopic reservoir: ileocecal compared with ileal neobladder.

PURPOSE: We compare the absorption of D-xylose and vitamin B12, and the metabolic status in ileocecal and ileal orthotopic neobladders. MATERIALS AND METHODS: D-xylose plasma levels after an oral load, body composition, plasma vitamin B12, acid base and electrolyte balance were studied in 33 patients with an ileocecal reservoir and 13 patients with an ileal reservoir. Mean followup was 55 months. Results of both types of operation and a healthy control group were compared. RESULTS: Plasmic levels of D-xylose and vitamin B12 were significantly lower in the ileal reservoir than in ileocecal reservoir group and normal controls. CONCLUSIONS: Despite an acceptable body composition, intestinal malabsorption could be present in patients with an ileal reservoir but the ileocecal tract appears to be safe.

Clinical review of 100 consecutive surgically treated patients with upper urinary tract transitional tumours.

OBJECTIVE: To determine the outcome of conservative or radical treatment in a retrospective study of 100 consecutive patients with upper urinary tract tumours. PATIENTS AND METHODS: From 1965 to 1995, 100 patients (78 men and 22 women, mean age 65 years, range 27-82) with upper urinary tract tumours were treated surgically, using nephroureterectomy with excision of a cuff of bladder in 53 and organ-sparing treatment in 47. The outcome was assessed as survival and recurrence during a follow-up of up to 15 years. RESULTS: After radical and organ-sparing treatment, the 15-year cancer-specific survival was 69% and 25%, respectively; metastases developed in 17% and 19% and global recurrence in 40% and 70%, respectively. While locoregional and bladder recurrences were similar in the two groups (9% vs 8% and 30% vs 38%, respectively), ureteric-stump recurrence in the conservative group was 23%. There were no significant differences in survival rates between patients with single or multiple presentation, or for localization, while the grading of the lesions proved to be an accurate prognostic indicator. CONCLUSION: This experience of urothelial neoplasia of the upper tract highlights the difficulty in diagnosing this pathology and in entrusting screening to a non-invasive technique such as urinary cytology. The percentage recurrence observed after organ-sparing therapy indicates that this treatment should be used cautiously.

[Diagnostic difficulties in renal leiomyosarcoma. Case report and review of the literature]. / Difficoltà diagnostiche nel leiomiosarcoma renale. Case report e review della letteratura.

The authors report a case of renal leiomyosarcoma and a review of the literature, underlining the difficulties of making a correct differential diagnosis with the benign neoplasms of the kidney and in performing correct surgical therapy.

The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years' experience.

OBJECTIVE: To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement. PATIENTS AND METHODS: Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation. RESULTS: All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred. CONCLUSIONS: The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

Bladder replacement in women: a new experience.

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

Vitamin B12 and folic acid plasma levels after ileocecal and ileal neobladder reconstruction.

OBJECTIVES: To compare the plasma levels of vitamin B12 and folic acid following resection of ileocecal or ileal segments used for orthotopic bladder substitution. METHODS: Hemoglobin, hematocrit, and plasma levels of vitamin B12 and folic acid were measured in 34 patients with ileocecourethrostomy (ICUS) and in 16 patients with ileal reservoir (IR), with a mean follow-up of 59.8 +/- 41.9 months. The results were compared with regard to both the type of operation and the length of time since surgery. RESULTS: The level of folic acid was normal in all patients. The mean level of vitamin B12 in the ICUS group was 413.67 +/- 160.45 ng/mL compared to 257.63 +/- 121.36 for the IR group. This difference was statistically significant. In the IR group, 18.75% of the patients had a level of vitamin B12 below normal. CONCLUSIONS: There is a tendency for vitamin B12 levels to fall in patients in whom the ileum is used. Resection of the ileocecal segment including the junction does not alter the level of vitamin B12.

Non-Hodgkin's lymphoma: a case report of a secondary bladder involvement.

Bladder secondary involvement rate in non-Hodgkin's lymphoma (NHL) reaches 13%. Nevertheless, clinical evidence of such an involvement is very rare (less than 0.5%). We report a case of a NHL arising from the Peyer's plaques of the gut and involving secondly the bladder. The onset symptomatology was urologic. Pathophysiology and clinical features of secondary bladder lymphoma are discussed.

Bladder replacement by detubularized ileal loop: 10 years of experience using a personal technique.

OBJECTIVE: To evaluate the results obtained with a technique of bladder replacement using a detubularized ileal tract, developed by the authors. PATIENTS AND METHODS: Since 1983, 34 patients have undergone an orthotopic bladder replacement using 35-40 cm of ileum, detubularized and shaped into an 'S' to create a neobladder with a capacity of 100-120 mL. The ureters were anastomosed directly to a 10 cm long intact afferent loop which serves as an anti-reflux mechanism, while a 2 cm long efferent, spatulated loop was used for urethral anastomosis. The mean (SD) follow-up was 32 (33) months. RESULTS: All the patients were continent during the day, with socially convenient intervals between voids; 3 years after the operation, 10 of 12 patients were continent during the night, with intervals of 2-4 h between voids. The mean post-void residual urine volume was 41 mL and no patient required self-catheterization. There were no derangements of the metabolic status of patients. CONCLUSION: This technique was applied knowing that a detubularized intestinal loop has the remarkable ability to increase in capacity over time. Therefore, to maintain the reservoir in good condition over a long period it is important to construct it with an intra-operative capacity of < 120 mL, thus reducing the length of intestine required. This may explain the satisfactory metabolic status of these patients. Moreover, the triplication of the mesentery helps to maintain the sphericity of the neobladder and provides support for the neobladder in the lower pelvis, where it retains the same position as a normal bladder.

Immunohistochemical quantitation of 4-aminobiphenyl-DNA adducts and p53 nuclear overexpression in T1 bladder cancer of smokers and nonsmokers.

An immunoperoxidase method, using a monoclonal antibody which recognizes 4-aminobiphenyl (4-ABP)-DNA adducts, was developed for the detection and quantitation of DNA damage in bladder tissue and applied to stored paraffin blocks of transurethral resection specimens of 46 patients with T1 bladder cancer. Mean relative staining intensity for 4-ABP-DNA adducts was significantly higher in current smokers (275 +/- 81, n = 24) compared to nonsmokers (113 +/- 71, n = 22) (P < 0.0001). There was a linear relationship between mean levels of relative staining and number of cigarettes smoked with lower levels in the 1-19 cig/day group (205 +/- 30, n = 5), compared to the 20-40 (289 +/- 40, n = 7) and the >40 cig/day group (351 +/- 57, n = 3)(P < 0.001). Nuclear overexpression of p53, analyzed by immunoperoxidase staining, was observed in 27 (59%) of the 45 stage T1 tumors analyzed. There was a significant correlation between p53 overexpression and recurrence of disease (odds ratio = 12.3, P < 0.01). Nuclear staining of p53 was also correlated with smoking status, cig/day and 4-ABP-DNA adducts. This work demonstrates that the immunohistochemical method has sufficient sensitivity for detection of 4-ABP-DNA adducts in human bladder samples. The method has several advantages including small sample size, the possibility of retrospective analysis of stored paraffin blocks, the ability to analyze binding in specific cell types, and a relatively low cost.

Three consecutive cases of adenomatoid tumour of the epididymis: histological considerations and therapeutical implications. Review of the literature.

Adenomatoid tumour is an uncommon neoplasm of the male genital tract. The Authors report their recent observation of three consecutive cases of adenomatoi tumour of the epididymis. In all cases the diagnosis was difficult and done only by an accurate histological examination. The treatment was conservative, consisting in the removal of the neoplasm. After a follow up of at least two years the patients do not show any sign of relapses confirming the validity of the surgical therapeutical approach performed. Because of the unfrequent observation of these forms and the difficulty in the diagnosis, the Authors stress the necessity of the surgical exploration with an accurate microscopic examination of the specimens. Moreover a review of the literature from a histological and therapeutical point of view was done and reported.

Could standardized cavernosometry be helpful in therapeutic management of veno-occlusive dysfunction?

PURPOSE: Due to the lack of a gold standard for performing cavernosometry, we selected 30 patients with veno-occlusive dysfunction to evaluate the internal relationships of cavernosometric parameters and their reliability for therapeutic decisions. MATERIALS AND METHODS: Cavernosometry was performed after injection of 20 to 40 micrograms of prostaglandin E1. Maintenance flow rates, intracavernous pressure decay following cessation of flow and intracavernous pressure changes after compression maneuvers were the main parameters considered. RESULTS: Cavernosometric results were standardized as grade 1-7 patients with maintenance flow rate less than 20 ml. per minute (mean 18 +/- 2.5) and intracavernous pressure decay 27.5 +/- 15%, grade 2-11 with maintenance flow rates significantly lower (p < 0.001) than grade 1 (mean 37 +/- 11 ml. per minute) and intracavernous pressure decay 33 +/- 20%, and grade 3-12 with only recorded induction flows greater than 70 ml. per minute and intracavernous pressure less than 50 mm. Hg. A strong statistical correlation (p < 0.01) was noted between maintenance flow rate and percent of intracavernous pressure decays. CONCLUSIONS: These parameters allowed us to choose different therapies, such as complex venous surgery, mixed pharmacotherapy or prosthetic implants. Good sexual function was restored in 85% of the cases. We can conclude that our model of standardized cavernosometry has made easier the therapeutic choices in patients who do not respond to intracavernous drugs.

Early experience of corpora cavernosa electromyography in impotent patients after radical cystoprostatectomy.

OBJECTIVES: To assess the effects of autonomic nerve damage on the basis of cavernous electrical changes. METHODS: A study was carried out on the cavernous electrical activity in healthy volunteers (controls) and impotent patients after radical cystoprostatectomy using a specific electromyographical device, the 'SPACE-recorder 7500'. RESULTS: A significant reduction in the amplitude of potentials was recorded after pharmacological stimulation in both the controls and impotent patients. The healthy controls showed amplitude values which were significantly higher than the impotent patients after radical cystectomy (715 +/- 141 vs. 381 +/- 227 microV, p < 0.01). After 'nerve-sparing' radical cystectomy with a mean amplitude similar to controls (500-700 microV), the patients showed rigid erections after injection of intracavernous drugs in a high percentage of cases. CONCLUSION: In our experience, corpora cavernosa electromyography seems a reliable method which can directly point out damage in the cavernous smooth muscle and the penile autonomic nerves.

Bilateral renal tumours: a hard surgical problem. Case report.

Three cases of bilateral renal tumours are reported. A radical nephrectomy in the side with the larger tumour and a nephron-sparing surgery (partial nephrectomy or enucleo-resection) in kidney with smaller lesions was performed in two cases. A bilateral partial nephrectomy was performed in the last patient (tumours larger than 5 cm). Two of them performed a needle CT-guided biopsy before surgery, but full disagreement was found between pre and post-operative histological results. In addition, we outline that a second lesion was found intraoperatively in the case n. 3, without any radiological and sonographic finding. We stress the importance of a conservative surgery in case of bilateral neoplasms. Only surgery could assure a careful staging and histological diagnosis.