Robot assisted radical cystectomy with Florence robotic intracorporeal neobladder (FloRIN): Analysis of survival and functional outcomes after first 100 consecutive patients upon accomplishment of phase 3 IDEAL framework.

INTRODUCTION: Aim of the study was to evaluate the Florence intracorporeal neobladder (FloRIN) oncological and functional outcomes at the end of assessment phase (phase 3) IDEAL-Guidelines. MATERIALS AND METHODS: This single-institution prospective series included consecutive patients treated with robot-assisted radical cystectomy (RARC) and FloRIN reconfiguration technique from February 2016 to June 2020. Functional features were evaluated six months after surgery. Patients were grouped into four quartiles according to time of radical cystectomy and impact of learning curve improvement was evaluated. RESULTS: One-hundred FloRIN were completed with a median console time of 373 (IQR: 312-415) minutes. Two cases were converted to open surgery. No intraoperative complications occurred. At pathological examination, 30% of patients were staged as pT ≤ 1 and 47% as pT ≥ 3. Transitional cell carcinoma was present in 87% of cases. Carcinoma in situ (CIS) and nodal involvement were observed in 38% and 29% of patients, respectively. At a median follow-up time of 17 (IQR: 7-28) months, 20 clinically relevant events (Clavien-Dindo≥3) occurred. Operative time significantly decreased throughout the series (median minutes 435; 395; 365 and 330 in the four quartiles, respectively; p < 0.001). Similarly, early Clavien-Dindo≥3 postoperative complications rate significantly decreased across the series (number of events: 1; 4; 0; 0; p = 0.03). Overall, 75% and 65% of patients achieved day-time and nigh-time continence, respectively. Twenty-seven patients experienced disease recurrence. Cancer-specific and overall survival were equal to 80%. CONCLUSIONS: RARC with FloRIN reconfiguration showed worthy functional and survival outcomes, with learning curve improvement significantly influencing operative time and early complications rate across series.

Long-term evaluation of modified orthotopic Y-shaped ileal neobladder (Tanta pouch) with left retro-colic chimney.

PURPOSE: In the present study, we evaluated the long-term results of modified Y-shaped orthotopic ileal neobladder (Tanta pouch) with trans-mesenteric left retro-colic chimney. PATIENTS AND METHODS: A total of 70 patients with invasive bladder cancer underwent radical cystectomy and modified Y-shaped orthotopic ileal neobladder. (The left chimney elongated to pass to the left side through a window in the mesentery of the pelvic colon and the ureters were implanted directly end to side, in both chimneys after doing good spatulation. RESULTS: The mean follow-up period ranged between 7 and 10 years (mean 7.8 years). 18 patients died during the period of follow-up. 6 months postoperatively, there was a spherical orientation of the pouch (The mean capacity was 542 ± 47 cm3) and the maximum intra-pouch pressure was 24 ± 3.2 cm H2O. Daytime continence was achieved in 93% of the patients and nighttime continence was achieved in 87%. Stress incontinence occurred in 15% and total incontinence in 2%. Renal function was stable in 93% of renal units. Stricture ureter was not recorded of any case. Of 14 renal units with preoperative dilated ureters, 5 units had improved postoperatively and the others had persistent reflux. 13 renal units (3 unilateral and 5 bilateral) with normal preoperative ureters had persistent postoperative reflux. Persistent reflux showed no influence on renal function. CONCLUSION: Modified Y-shaper pouch is suitable for short, dilated ureters. Longitudinal orientation of the pouch facilitates ileo-urethral anastomosis, especially with short mesentery. Long-term follow-up for direct uretero-ileal anastomosis did not show deterioration of the renal function.

Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire.

STUDY OBJECTIVE: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. DESIGN: Secondary analysis of a prospective randomized controlled trial. SETTING: Three academic research centers. PATIENTS: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. INTERVENTIONS: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. MEASUREMENTS AND MAIN RESULTS: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively). CONCLUSION: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.).

Trypan Blue for the Assessment of Filtering Bleb Function During Cataract Surgery.

PURPOSE: Phacoemulsification has been cited as a possible cause of bleb failure in eyes with prior trabeculectomy. No method has been developed to directly evaluate the risk of bleb failure after phacoemulsification. We investigate the use of trypan blue during cataract surgery in the setting of a preexisting trabeculectomy to evaluate the functional status of the bleb and predict postoperative bleb function. MATERIALS AND METHODS: In total, 14 patients contributing 1 eye each with a history of prior trabeculectomy with mitomycin C undergoing phacoemulsification with intraocular lens implantation were enrolled in this prospective, nonrandomized clinical trial. At the time of phacoemulsification, trypan blue was instilled into the anterior chamber before capsulorhexis creation. Staining of the bleb was grouped as being mild or diffuse using intraoperative photographs. These eyes were followed for 1 year postoperatively and evaluated for intraocular pressure (IOP) control. RESULTS: The change in IOP was not significantly different between the 2 groups (P=0.14). A trend towards greater need for IOP-lowering medications was noted (P<0.10) in eyes with mild bleb staining. No statistically significant difference in rates of decreased bleb function was noted at 1-year follow-up after phacoemulsification. CONCLUSION: The intensity of bleb staining with trypan blue during phacoemulsification is not associated with changes in IOP postoperatively. A trend towards decreased need for IOP-lowering medications was noted in eyes with diffuse bleb staining at 1 year after cataract surgery.

Long-term functional outcomes after replacement of the esophagus with gastric, colonic, or jejunal conduits: a systematic literature review.

It is generally recognized that in patients with an intact stomach diagnosed with esophageal cancer, gastric tubulization and pull-up shall always be the preferred technique for reconstruction after an esophageal resection. However, in cases with extensive gastroesophageal junction (GEJ) cancer with aboral spread and after previous gastric surgery, alternative methods for reconstruction have to be pursued. Moreover, in benign cases as well as in those with early neoplastic lesions of the esophagus and the GEJ that are associated with long survival, it is basically unclear which conduit should be recommended. The aim of this study is to determine the long-term functional outcomes of different conduits used for esophageal replacement, based on a comprehensive literature review. Eligible were all clinical studies reporting outcomes after esophagectomy, which contained information on at least three years of follow-up after the operation in patients who were older than 18 years of age at the time of the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library, and EMBASE databases was performed, reviewing medical literature published between January 2006 and December 2015. The scientific quality of the data was generally low, which allowed us to incorporate only 16 full text articles for the final analyses. After a gastric pull-up, the proportion of patients who suffered from dysphagia varied substantially but seemed to decrease over time with a mild dysphagia remaining during long-term follow-up. When reflux-related symptoms and complications were addressed, roughly two third of patients experienced mild to moderate reflux symptoms a long time after the resection. Following an isoperistaltic colonic graft, the functional long-term outcomes regarding swallowing difficulties were sparsely reported, while three studies reported reflux/regurgitation symptoms in the range of 5% to 16%, one of which reported the symptom severity as being mild. Only one report was available after the use of a long jejunal segment, which contained only six patients, who scored the severity of dysphagia and reflux as mild. Very few if any data were available on a structured assessment of dumping and disturbed bowel functions. Few high-quality data are available on the long-term functional outcomes after esophageal replacement irrespective of the use of a gastric tube, the right or left colon or a long jejunal segment. No firm conclusions regarding the advantages of one graft over the other can presently be drawn.

Robotic Intracorporeal Orthotopic Neobladder: Urodynamic Outcomes, Urinary Function, and Health-related Quality of Life.

BACKGROUND: Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required. OBJECTIVE: To evaluate urodynamic features of iONB and bladder cancer-specific and general health-related quality-of-life (HRQOL) outcomes. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score. RESULTS AND LIMITATIONS: The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p<0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p<0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm(3) (range 339-1001). BCI mean scores for urinary function (p=0.58) and urinary bother (p=0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs. 19%; ≤2 pads 84% vs. 79%), as reflected by total pad usage (p=0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group. CONCLUSIONS: iONB had adequate UDS characteristics and comparable bladder cancer-specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up. PATIENT SUMMARY: We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group.

Comparison of two laparoscopic peritoneal vaginoplasty techniques in patients with Mayer-Rokitansky-Küster-Hauser syndrome.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the technical feasibility and long-term anatomical and functional outcomes of a novel laparoscopic vaginoplasty using single peritoneal flap (SPF) and Davydov's laparoscopic technique in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. METHODS: From September 2004 to September 2013, a comparative study was conducted of 98 patients with MRKH syndrome who underwent either laparoscopic vaginoplasty using SPF (SPF group, 62 cases) or Davydov's laparoscopic technique (Davydov group, 36 cases) in a university-based tertiary care hospital. Intraoperative and postoperative parameters and anatomical examination findings of the two groups were compared. Functional results were assessed using the Female Sexual Function Index (FSFI). RESULTS: All surgical procedures were performed successfully, with no intraoperative complications in either group. Patients in the SPF group had a significantly shorter operative time and less intraoperative blood loss than patients in the Davydov group. The postoperative course was identical for all patients in the two groups. The mean length and width of the neovagina in the two groups at hospital discharge, the 6-month follow-up, and the 12-month follow-up did not differ significantly. There were no significant differences between the groups with regard to the postoperative FSFI scores at 12 months after surgery. CONCLUSIONS: Although the long-term anatomical and functional outcomes of the two laparoscopic peritoneal vaginoplasty techniques are similar, laparoscopic vaginoplasty using SPF, which has many advantages and is easily performed by the gynecologist, is a more feasible and effective approach to creating a neovagina in patients with MRKH syndrome.

The clinical, structural, and biological features of neovaginas: a comparison of the Frank and the McIndoe techniques.

OBJECTIVE: To compare two methods of neovagina construction, the Frank and McIndoe techniques, in terms of structural and biological aspects. STUDY DESIGN: A total of 55 subjects were included in this retrospective study: 43 underwent the Frank technique (FT) and 12 underwent the McIndoe technique (MT). A clinical evaluation and a comparison of the structural (color, shine, presence of hair, and histology) and biological (bacteriological, pH, and hormonal determinations) features were performed. Statistical analysis was performed using the Fisher and Mann-Whitney tests. RESULTS: The time to achieve a functional neovagina using the FT was longer than when using the MT (9.8±5.3 versus 5.8±2.9 months) (p=0.01). The neovaginal wall of the MT skin grafts was more rigid and drier, and it did not exhibit a shine in the way that the FT skin grafts did. The lining of the cavity formed by the FT in all subjects was similar to that of vaginal mucosa, whereas the lining formed by the MT persisted as a skin graft in 83.3% of the cases. The pH was lower for the FT (p<0.01), and Döderlein bacilli were present in 90% of the FT neovaginas but absent from the MT neovaginas. In the latter, flora with anaerobic bacteria was present. Hormonal cytology showed estrogen activity in 100% of the FT neovaginas, but there was no such activity in the MT neovaginas. CONCLUSIONS: Our data suggest that the FT may be clinically, structurally, and biologically superior to the MT for the creation of neovaginas and is also less costly.

Perivascular tissue mediated relaxation - a novel player in human vascular tone regulation.

Perivascular tissue (PVT) modulates vascular tone, releasing adventitia/adipocyte derived relaxing factor (ADRF). Its physiological role remains unclear. We studied isolated internal thoracic artery (ITA) segments obtained from 132 patients subjected to coronary artery bypass grafting. The vessels were skeletonized in vitro and the ITA rings and PVT were incubated in separate isolated organ baths. Skeletonized ITA segments were first precontracted with 10(-5.5)mol/L 5-hydroxytryptamine hydrochloride. The PVT was next transferred to the ITA tissue bath. This resulted in relaxation of ITA, presumably related to ADRF release from PVT which was floating freely in the tissue bath. The in-vitro relaxation responses were then correlated to patients' characteristics - including demographics, clinical and laboratory data, as well as therapy. Perivascular tissue transfer resulted in 49.7 ± 26.2% relaxation of precontracted ITA segments. In multiple linear regression modelling, the relaxation of ITAto PVT was negatively related to patient age (ß = -0.67; 95% CI -1.17 - -0.17; P = 0.009), symptoms of CCS class 4 angina (ß = -20.11; 95%CI -32.25 - -7.97; P = 0.001), and positively to body mass (ß = 0.37; 95%CI 0.08 - 0.67; P = 0.01) and lack of heart failure symptoms (NYHA class 1) (ß = 9.06; 95%CI 0.33 - 17.79; P = 0.04). The relaxation response to PVT was not related to patients' sex, diabetes, hypertension, lipid profile or therapy in both univariate and multivariate analysis. PVT might play an important role in regulating vascular tone in humans as exemplified by its changing physiological function with age and in atherosclerosis.

Sexual and functional results after creation of a neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome: a comparison of nonsurgical and surgical procedures.

OBJECTIVE: To compare nonsurgical and surgical procedures for creation of a neovagina in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome in terms of sexual satisfaction. STUDY DESIGN: We report a cross-sectional study of 91 women with MRKH syndrome undergoing a neovagina creation procedure. They were members of the French National Association of Women with MRKH syndrome. We analyzed all answers to a questionnaire mailed to each woman. The questionnaire solicited short answers concerning the diagnosis and the neovagina procedure, and included the standardized FSFI (Female Sexual Function Index) questionnaire. All analyses were performed using the chi-squared test and Student's t-test. A p-value of <0.05 was considered statistically significant. RESULTS: Forty women answered the questionnaire. Twenty had been treated by Frank's method (non-surgical group) and 20 had undergone a surgical procedure, sigmoid vaginoplasty (12 cases) or Davidov's technique (8 cases) (surgical group). The mean time after neovagina creation was 7 years (range 1-44 years). The population characteristics did not differ significantly between the nonsurgical and surgical groups. The total FSFI score indicated good and similar functional results in the two groups (25.3±7.5 versus 25.3±8.0). CONCLUSIONS: Functional sexual outcomes after nonsurgical and surgical methods were similar. Therefore, the Frank's method should be proposed as first line therapy because it is less invasive than surgical procedures. In the case of failure of this technique or of refusal by the patient, surgical reconstruction may then be offered.

Restoration of anal sphincter tone by graciloplasty: a report of five cases.

Stool incontinence can be as a result of congenital or acquired anal sphincter problems. It is a devastating state for a patient not to be able to control stools resulting into continued feacal soiling. It reduces an individual to a dejected and depressed person who becomes a social misfit. Hence any procedure that can alleviate this state is normally highly appreciated. Various techniques have been quoted in literature and use of gracilis muscle to form a neosphincter is one of them. Dynamic graciloplasty, is a technique whereby electrodes have been implanted into gracilis muscle and is connected to an implantable pulse generator which provides progressive levels of stimulation to convert the fast twitch, fatigue prone muscle fibres to a slow twitch, fatigue resistant firbres over eight week training period (1,2,3). This has shown improved efficacy over the static graciloplasty (3). In this case report, five patients with stool incontinence from different aetiologies are presented, all having been managed by static graciloplasty and intense physiotherapy with good outcomes reported.

Results of reconstruction with jejunal pouch after gastrectomy: correlation with gastrointestinal motor activity.

BACKGROUND/AIMS: To investigate if restoration of esophago-intestinal or esophago-gastric continuity with a jejunal pouch after total or proximal gastrectomy has clinical benefits. METHODS: We reviewed all relevant reports published after 1990 that dealt with the clinical results of reconstruction with a jejunal pouch after total and proximal gastrectomies and correlated those findings with results for gastrointestinal motility. Reports were chosen from a search of the literature using PubMed. RESULTS: After total gastrectomy, the benefit of a jejunal J pouch interposition was not apparent compared to simple jejunal interposition; indeed, one trial concluded that simple interposition was better than pouch interposition in terms of food intake. In contrast, results with a jejunal J pouch during Roux-en-Y (RY) type reconstruction were better than with conventional RY reconstruction in terms of food intake, nutritional status, body weight (BW) and symptoms. Advantages were also shown for a jejunal pouch with an inverted U shape interposed between the esophagus and residual stomach after proximal gastrectomy. Reconstruction using a jejunal pouch after proximal gastrectomy was better than esophagogastrostomy or simple jejunal interposition in terms of food intake, BW and symptoms. There were not enough data to conclude any benefits of a jejunal J pouch between the gastric remnant and the duodenum after distal gastrectomy. CONCLUSIONS: Clinical results of restoration of intestinal continuity with a jejunal pouch after total and proximal gastrectomies may be attributed, at least in part, to the relationship between the motor activity of the gastric remnant, duodenum and jejunal pouch.

Numerical analysis of pouch filling and emptying after laparoscopic gastric banding surgery.

BACKGROUND: Previous studies have indicated that pouch volume and stoma size are two important factors related to weight loss after laparoscopic gastric banding in morbid obese patients. We hypothesized that there was association among the wall stress, pouch volume, and stoma size in a model for the filling and emptying phases of the pouch. METHODS: A numerical pouch model with variable pouch volume and stoma size was generated. Uniaxial tensile testing was performed on fundus strips from fresh pig stomach and the mass flow of filling and emptying of the pouch was simulated numerically. RESULTS: There was an overall qualitative agreement on the volume change between the simulated results and the clinical recording. Increasing the pouch volume size from 22 to 105 ml caused a decrease of the maximum circumferential stress from 14.14 to 11.80 kPa and the maximum longitudinal stress from 9.87 to 6.70 kPa in the pouch wall at the same degree of filling. Decreasing the stoma diameter from 27 to 10 mm caused an increase of the maximum circumferential stress from 11.46 to 12.78 kPa and a decrease of the maximum longitudinal stress from 10.34 to 8.69 kPa. CONCLUSION: Both the pouch volume and stoma size are important determinants of mechanical wall stress, wall strain, and pouch emptying and hence may affect satiety and weight loss. This information may be important in understanding the mechanical behavior of pouches and for the development of more advanced numerical models in the clinical management of the surgery.

Techniques of reconstruction after total gastrectomy for cancer.

BACKGROUND: Jejunal pouch formation and restoration of duodenal transit have been suggested for reconstruction after total gastrectomy. Opinions about the clinical value vary. METHODS: The literature was searched for prospective randomized trials comparing reconstructive procedures after total gastrectomy for malignancy. Reports with at least an English or German abstract were included. Immediate results were evaluated in terms of postoperative deaths and complications. Long-term outcome was analysed using trends in bodyweight and quality of life. RESULTS: A total of 19 randomized trials including 866 patients was identified. The operative risk of total gastrectomy was low, with a median mortality rate of 0 (range 0-22) per cent, irrespective of the method of reconstruction. Neither gastric substitution nor restoration of duodenal transit was associated with significant procedure-related complications. Results for specific reconstructions varied considerably within and between individual trials. Jejunal pouch reconstruction, but not restoration of duodenal passage, was associated with improved food intake and a tendency for weight gain in the early postoperative months. A favourable perception of quality of life persisted in the long term in some studies. CONCLUSION: Preservation of duodenal transit offers little clinical benefit. Construction of a small-bowel reservoir after total gastrectomy should be considered to improve early postoperative eating capacity, bodyweight and quality of life.

A new technique for creation of a sigmoid neobladder for urinary reconstruction: clinical outcome in 42 men.

OBJECTIVES: To present the results of a new technique for construction of a sigmoid neobladder after radical cystectomy. METHODS: Forty-two men, 43 to 74 years of age (mean age 62 +/- 8), underwent radical cystectomy for invasive bladder cancer and had a sigmoid neobladder created using a modification of the standard ureterointestinal anastomosis with rotation of the reservoir. The mean follow-up of this retrospective study was 35 +/- 20 months (range 6 to 90). The blood chemistry was analyzed routinely during follow-up, and complications, continence, and voiding pattern were assessed at regular intervals. RESULTS: There were 21 early complications in 14 patients: persistent urinary leakage in 2; wound infection in 9; prolonged ileus in 4; leakage from the colonic anastomosis in 2; and pulmonary embolus in 2. One patient each had venous thrombus of the lower extremities and methicillin-resistant Staphylococcus aureus colitis. One patient died in the perioperative period of massive pulmonary embolus, yielding a mortality rate of 2.4%. Eleven late complications occurred in 9 patients. Stenosis of the ureterointestinal anastomosis developed in 2 of 82 anastomoses, stenosis of urethral anastomosis in 4, and neobladder-ureteral reflux in 1. A reservoir stone was found in 1 patient, and adenoma and adenocarcinoma of the reservoir occurred in 1 patient each. One patient developed symptomatic hyperchloremic metabolic acidosis, and routine electrolyte evaluation revealed a slight metabolic acidosis in 6 patients. Hypovitaminosis B(12) did not occur in any patients. Of the 42 patients, 40 could void volitionally without catheterization. Patient satisfaction on continence, by day and night, was 77.3% and 72.7%, respectively. The mean neobladder capacity and the mean residual urine volume was 375 +/- 116 mL (range 234 to 624) and 68 +/- 86 mL (range 4 to 365), respectively. CONCLUSIONS: The modified sigmoid neobladder provides satisfactory results after radical cystectomy.

Chronic outcome of proximal gastrectomy with jejunal pouch interposition in dogs.

BACKGROUND: To prevent or minimize postgastrectomy complications, proximal gastrectomy with an interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to improve quality of life for the patients. However, the utility of this surgical method has only been evaluated clinically and no reports have been published concerning animal studies. Therefore, we carried out an experiment in beagle dogs to investigate the utility of proximal gastrectomy with an interposed jejunal pouch. METHODS: Female beagle dogs weighting 8.0-10.0 kg were divided into two groups that underwent proximal gastrectomy with jejunal pouch interposition (JP group) and esophagogastrostomy (EG group). The time course of the electrophysiological changes on electromyograms were compared between the JP and EG groups. RESULTS: Electrophysiologically, a significant difference was noted between the two groups on the number of action potentials per unit time, the mean amplitude, and the length of the resting period in the preprandial state. All parameters tended to be normalized sooner after surgery in the JP group. CONCLUSIONS: The clinical superiority of jejunal pouch interposition was suggested experimentally to the same extent on electromyograms.

Vaginal reconstruction utilizing sigmoid colon: Complications and long-term results.

BACKGROUND/PURPOSE: The use of sigmoid colon segments to repair congenital deformities of the vagina is well established. There are little data, however, on complications or functional results in these patients. The purpose of this study was to evaluate complication rates and long-term patient outcomes in the use of sigmoid segments in vaginal reconstruction for congenital anomalies. METHODS: The authors identified 28 patients who underwent vaginal reconstruction with sigmoid colon segments between 1985 and 2000 at their institution. Patient charts were reviewed for surgical technique, complication rates, cosmetic results, functional results, and psychosocial development. Patients were recalled for physical examinations and personal interviews to assess current status. RESULTS: Of the 28 patients, 13 had male pseudohermaphroditism, 6 had Mayer-Rokitansky-Kuster-Hauser syndrome, 2 had true hermaphroditism, 2 had mixed gonadal dysgenesis, 2 had common urogenital sinus syndrome, 2 had adrenogenital syndrome, and 1 had penile agenesis. Mean patient age was 16 years (range, 6 to 21 years). Mean follow-up was 6.2 years (range, 2 months to 15 years). Postoperative complications included introital stenosis (4 patients), mucosal prolapse (4), partial small bowel obstruction (2), perineal wound hematoma (2), superficial wound infection (2), and vaginal prolapse (1). None of the complications have affected long-term patency or cosmesis of the neovagina, nor has mucous production significantly affected quality of life. Fourteen of 16 (88%) adult patients are heterosexually active, 1 is homosexually active, and 1 is asexual. Of the 14 heterosexually active patients, 11 (79%) are "very satisfied" with their psychosexual development and 3 are "comfortable." Four patients are married, and 1 has carried a child to term. All adult patients felt that the appropriate time to undergo surgery was in adolescence. CONCLUSIONS: Reconstruction with sigmoid segments is an effective approach for many congenital conditions requiring vaginal reconstruction. Although surgical outcomes are not perfect, appropriately timed reconstructive vaginal surgery can provide most patients with an improved quality of life. For the best long-term results, a multidisciplinary team must be available from infancy to supply comprehensive support.

Surgically created double-orifice left atrioventricular valve: a valve-sparing repair in selected atrioventricular septal defects.

OBJECTIVES: Some features of the left atrioventricular valve (large mural leaflet, dystrophic tissue) represent a challenge for repair of atrioventricular septal defects without postoperative regurgitation. A retrospective study was conducted to evaluate the results of surgically creating a double-orifice left atrioventricular valve in such circumstances. Clinical results were analyzed according to valvular and subvalvular left atrioventricular valve measurements in pathologic specimens with atrioventricular septal defects. METHODS: Among 157 patients operated on for atrioventricular septal defect since October 1989, 10 patients underwent primary repair (n = 8) or reoperation (n = 2) by this procedure. Median age at repair was 3.3 years (0.1-33 years). Anatomic types were complete (n = 3), intermediate (n = 5), and partial (n = 2). Preoperative moderate to severe left atrioventricular valve regurgitation was present in 6 patients. After the repair (two-patch technique in complete atrioventricular septal defect, cleft closed in each case), these 10 patients were found to have moderate to severe residual regurgitation not amenable to repair by annuloplasty. The top edge of the mural leaflet was anchored to the facing free edge of the cleft. RESULTS: No hospital death or morbidity was observed. Left atrioventricular valve regurgitation was absent or trivial (8 patients) and mild (2 patients). Color-coded echocardiography did not show significant left atrioventricular valve stenosis. The mean diastolic pressure gradient across the left atrioventricular valve was 3.2 +/- 1.1 mm Hg (1.4-4.5 mm Hg). At a median follow-up of 72 months (6-91 months), there was 1 late death, unrelated to left atrioventricular valve malfunction, due to pulmonary vascular obstructive disease. Left atrioventricular valve regurgitation did not increase over time, except in 1 patient in whom regurgitation recently progressed from mild to moderate. At rest, the mean diastolic pressure gradient across the left atrioventricular valve was 3.8 +/- 2.9 mm Hg (1.5-11.2 mm Hg). One child had an early moderate stenosis without pulmonary hypertension. Studies on pathologic specimens (n = 34) indicated that long chordal lengths and large mural leaflet size are essential independent anatomic features to assess its feasibility. CONCLUSIONS: Surgical creation of a double-orifice left atrioventricular valve is an effective additional procedure for repair of atypical cases of atrioventricular septal defect. The operation may decrease the need for reoperation or left atrioventricular valve replacement.

[Pseudo-continent perineal colostomy. Results and techniques]. / Colostomie périnéale pseudo-continente. Résultats et technique.

OBJECTIVE: This prospective study was conducted to assess functional results obtained after pseudo-continent perineal colostomy using the Schmidt procedure. METHODS: Functional outcome was assessed in 40 patients who had undergone amputation of the rectum for cancer and pseudo-continent perineal colostomy reconstruction between 1989 and 1995 in our institution. The cancer pathology, operative procedure and post-operative care were noted. Morbidity, functional outcome and degree of patient satisfaction were recorded. Mean follow-up was 45 months (18-87) in 100% of the patients. RESULTS: There were no operative deaths. Twenty patients had post-operative complications and 2 patients required early conversion to definitive abdominal colostomy due to severe perineal complications. Function outcome showed normal continence in 4 patients, air incontinence in 23, occasional minimal leakage in 9 and incontinence requiring iliac colostomy in 2. Eighty-six percent of the patients were highly satisfied or satisfied with their continence capacity. DISCUSSION: Pseudo-continent perineal colostomy is a reliable technique which can be proposed as an alternative to left iliac colostomy after amputation of the rectum for cancer if a rigorous procedure is applied: careful patient selection, informed consent, rigorous surgical procedure, daily life-long irrigation of the colon.