Description of a novel murine model for ileocystoplasty and early histologic changes.

There is concern that bladder augmentation with bowel segments predisposes toward the development of carcinoma. Additionally, patients with neurogenic bladder and bladder cancer often present with advanced stage and have poor survival. Cellular hyperproliferation at the urointestinal junction (UIJ) has been implicated in this scenario. We aimed to develop a reproducible murine model of ileocystoplasty (ICP). We also performed preliminary analysis of any early histologic changes with focus on cellular proliferation at the UIJ. Fifteen 6- to 8-week-old female C57BL/6 mice underwent ICP, where a 1-cm ileal segment was used for bladder augmentation. Four sham mice underwent cystotomy and closure, and four mice did not undergo surgery. The mice were euthanized at 12 weeks postsurgery, and paraffin sections were stained for hematoxylin and eosin (H&E). Cellular proliferation was investigated using Ki-67. A novel model of ICP in mice was developed and demonstrated to be technically feasible in approximately 60 min under the operating microscope. Twelve-week postsurgical survival rates were 80% (12 of 15). The surviving mice had a similar weight gain as the sham mice. H&E sections showed thickened urothelium (six to 10 cell layers) at the UIJ, but sparse mitotic figures and no dysplastic changes. Ki-67 staining was rare in the urothelium, and showed no differences between the sham and ICP mice in the bladder or at the UIJ. We here demonstrate the first murine model of ICP. Preliminary studies did not show evidence of early hyperproliferation at the UIJ or in the bladder, but further long-term studies as well as studies with transgenic mice are warranted.

Sacral neuromodulation in diabetic patients: success and complications in the treatment of voiding dysfunction.

AIMS: We compared success rates, subsequent complications, and possible indications for success of sacral neuromodulation (SNM) for urinary voiding dysfunction in diabetic and non-diabetic patients. METHODS: Thirty-two diabetic patients (mean age 61.8 years, range 27-83) with urge incontinence, urgency-frequency syndrome, and/or urinary retention refractory to non-surgical treatment were retrospectively evaluated along with 211 non-diabetic patients (mean age 54.1 years, range 20-86) with similar symptoms. All patients who experienced >or=50% reduction in urinary symptoms following a 7- to 21-day test period went on to permanent SNM device implantation. RESULTS: No significant difference was found with respect to successful conversion rates from the test period to permanent implantation between diabetic and non-diabetic patients. Long-term success rates at a mean followup of 29.3 months following permanent device implantation for diabetic patients were 69.2% of those with urge incontinence, 85.7% of those with urgency-frequency, and 66.7% of those with urinary retention. The non-diabetic cohort had success rates of 67.0% for urge incontinence, 67.8% for urgency/frequency, and 58.2% for urinary retention (P = 0.823, 0.157, and 0.631, respectively). No patient experienced intraoperative complications. Nine of 24 (37.5%) devices were explanted postoperatively in diabetic patients compared with 36 of 141 (25.5%) in non-diabetic patients (P = 0.224). The number of explants due to infection was higher in diabetic patients (16.7%) versus non-diabetic patients (4.3%; P = 0.018). CONCLUSIONS: No difference in long-term success rates was seen in diabetic patients when compared with similar, non-diabetic patients. Diabetic patients did, however, have a higher incidence of device explantation due to infection.

Combination of BCG and interferon intravesical immunotherapy: an update.

OBJECTIVE: To provide an update on the use of interferon (IFN) in the treatment of non-muscle invasive bladder cancer (NMIBC). METHODS: A literature review of intravesical IFN was performed. RESULTS: In vitro evidence suggested that IFN combined with BCG may have a synergistic effect on the immune response, and treatment regimens with IFN have used reduced BCG dosage in an attempt to reduce toxicity. IFN combined with BCG may salvage some patients, single-course BCG failures or late relapsers, while those that relapse quickly may be destined to failure. However, based on the results of a recently reported randomized trial, the addition of IFN may not improve efficacy in BCG naïve patients. CONCLUSIONS: BCG plus IFN remains an alternative in selected patients with NMIBC who fail intravesical BCG.

Evaluation of efficacy of four laparoscopic needle drivers.

INTRODUCTION: To evaluate the impact of needle driver design on laparoscopic suturing skills by experts and novices. METHODS: Three experienced laparoscopic surgeons and 3 novice junior residents were asked to perform a fixed set of suturing tasks in a laparoscopic pelvic-trainer. The laparoscopic needle drivers compared were (1) the Ethicon driver (E 705R), (2) Karl Storz (KS) pistol grip (26173 KC), (3) KS finger grip (26167 SK), and (4) KS palm grip (26173 ML). Times were recorded for each operator to grasp and position a needle for suturing in a particular angle, as well as to throw a horizontal and a vertical stitch and tie a single square knot using 2-0 Vicryl suture with a taper CT-1 needle. Subsequently, participants were asked to complete a subjective questionnaire rating the drivers. RESULTS: The average suturing time provided the most discriminatory power in comparing the needle drivers. For experienced operators, the KS pistol grip allowed faster suturing times than did the KS finger grip and the KS palm grip but not the Ethicon driver. For novice users, the Ethicon driver allowed faster suturing times than did the KS finger grip but not the KS pistol grip or the KS palm grip. In the subjective questionnaire, the KS pistol grip received the highest scores, and the KS finger grip received the lowest scores. CONCLUSION: Novice laparoscopists performed best with the KS pistol grip as well as the Ethicon laparoscopic needle drivers while experienced laparoscopists performed best with the pistol grip KS needle driver.

Irrigation and drainage properties of three-way urethral catheters.

OBJECTIVES: To evaluate in an in vitro study the irrigation and drainage capabilities of a variety of available catheters. Three-way Foley catheters are used when irrigation of the bladder is anticipated to prevent or manage blood clots in the bladder. METHODS: Six operators applied maximal one-handed pressure irrigation with a catheter-tip syringe through the irrigation and drainage ports of the Bardex and Dover three-way catheters (16F to 26F). Maximal manual irrigation flow was recorded using a flowmeter. Continuous gravity irrigation and drainage flows were measured by suspending a 2-L irrigation bag 80 cm above the catheters and fastening an artificial bladder to the drainage tip of each Foley catheter with the catheter balloon inflated to 30 mL. RESULTS: The Bardex 22F and 24F catheters had superior manual irrigation using the irrigation port (maximal urinary flow rate 8.9 +/- 1.3 mL/s and 9.5 +/- 1.5 mL/s, respectively, P < 0.000001) compared with the Dover 22F and 24F catheters. The Bardex and Dover 22F catheters (maximal urinary flow rate 29.0 +/- 1.9 mL/s and 29.3 +/- 1.9 mL/s, respectively, P = 0.66) and 24F catheters (maximal urinary flow rate 30.5 +/- 2.0 mL/s and 30.6 +/- 1.2 mL/s, respectively, P = 0.83) performed equally in manual irrigation using the drainage port. The Bardex 22F (average flow rate 1.6 +/- 0.1 mL/s, P < 0.00001) and 24F (average flow rate 1.7 +/- 0.0 mL/s, P < 0.000001) catheters exhibited better continuous irrigation and flow than the Dover 22F and 24F catheters. CONCLUSIONS: Three-way catheters are placed in situations in which efficient bladder irrigation is essential for patient safety. The Bardex 22F to 26F catheters optimized continuous bladder irrigation of the catheters tested.

Novel device to assist urethrovesical anastomosis during laparoscopic radical prostatectomy.

We evaluated a novel urethral sound (Benique sound-Karl Storz) to assist suturing during laparoscopic radical prostatectomy. This sound provides for a more secure grip compared with the traditional sound, thereby affording controlled traction of the gland during the procedure and smooth coordinated movements of the sound during the anastomosis.

Percutaneous nephrostomy catheters: drainage flow and retention strength.

OBJECTIVES: To evaluate the impact of percutaneous nephrostomy catheter configuration on drainage flow and retention strength. METHODS: The Cook nephrostomy 16F (symmetric balloon), Bardex Council 16F (eccentric balloon), Microvasive Flexima 14F (pigtail), and Bardex Malecot 16F (flange) nephrostomy catheters were attached to an artificial renal pelvis (12-in.-round latex balloon). The balloon was subsequently filled with either 60 mL of water or orange juice with pulp, and gravity drainage of this fluid was recorded as flow into a flowmeter. Using a Force Five Model FDV-100 force gauge, the retention strength was tested by measuring the force required to pull the nephrostomy catheter through an 8-mm hole in a 35-mm-thick biologic tissue specimen (bologna). RESULTS: The maximal flow rate using both orange juice and saline was significantly greater for the Cook nephrostomy than for the Microvasive Flexima, Bardex Malecot, and Bardex Council catheters (P < or = 0.016). The average flow rate using saline for the Cook nephrostomy catheter was significantly greater than for all other catheters (P < or = 0.02) and was significantly greater than for the Microvasive Flexima and the Bardex Council catheters (P < or = 0.036) using orange juice. The retention strength was strongest for the Cook nephrostomy catheter (3.41 +/- 0.14 lb) compared with the Bardex Council (1.75 +/- 0.1), Microvasive Flexima (1.35 +/- 0.3), and Bardex Malecot (0.29 +/- 0.03) catheters. In addition, the Microvasive Flexima catheter resulted in greater maceration of the biologic tissue after forceful dislodgement. CONCLUSIONS: The results of this study have demonstrated that the Cook nephrostomy catheter combines strong drainage flow and strong retention strength during in vitro testing. Clinical evaluations of the ease of use and patient comfort are warranted.