Evaluating the role of total organic carbon in predicting the treatment efficacy of biosand filters for the removal of Vibrio cholerae in drinking water during startup.

AIMS: In biosand filters (BSF), treatment is largely driven by the development of a biolayer (schmutzdecke) which establishes itself during the startup phase. In this study, the effect of changing influent total organic carbon (TOC) loading on the removal efficiency of Vibrio cholerae in laboratory-operated BSFs was quantified. METHODS AND RESULTS: BSFs were charged with high, medium or low TOC influents and removal efficacy and schmutzdecke composition was monitored over 2 months. The highest V. cholerae removal efficiencies were observed in the BSF receiving the lowest TOC. Schmutzdecke composition was found to be influenced by influent TOC, in terms of microbial community structure and amount of extracellular polymeric substance (EPS). CONCLUSIONS: Physical/chemical attachment was shown to be important during startup. The BSF receiving influent water with lower TOC had a higher attachment coefficient than the BSF receiving high TOC water, suggesting more physical/chemical treatment in the lower TOC BSF. The high TOC BSF had more EPS than did the biofilm from the low-TOC BSF, suggesting that schmutzdecke effects may be more significant at high TOC. SIGNIFICANCE AND IMPACT OF THE STUDY: Overall, this study confirms that influent water characteristics will affect BSF treatment efficacy of V. cholerae especially during the startup phase.

Identification of stromally expressed molecules in the prostate by tag-profiling of cancer-associated fibroblasts, normal fibroblasts and fetal prostate.

The stromal microenvironment has key roles in prostate development and cancer, and cancer-associated fibroblasts (CAFs) stimulate tumourigenesis via several mechanisms including the expression of pro-tumourigenic factors. Mesenchyme (embryonic stroma) controls prostate organogenesis, and in some circumstances can re-differentiate prostate tumours. We have applied next-generation Tag profiling to fetal human prostate, normal human prostate fibroblasts (NPFs) and CAFs to identify molecules expressed in prostatic stroma. Comparison of gene expression profiles of a patient-matched pair of NPFs vs CAFs identified 671 transcripts that were enriched in CAFs and 356 transcripts whose levels were decreased, relative to NPFs. Gene ontology analysis revealed that CAF-enriched transcripts were associated with prostate morphogenesis and CAF-depleted transcripts were associated with cell cycle. We selected mRNAs to follow-up by comparison of our data sets with published prostate cancer fibroblast microarray profiles as well as by focusing on transcripts encoding secreted and peripheral membrane proteins, as well as mesenchymal transcripts identified in a previous study from our group. We confirmed differential transcript expression between CAFs and NPFs using QrtPCR, and defined protein localization using immunohistochemistry in fetal prostate, adult prostate and prostate cancer. We demonstrated that ASPN, CAV1, CFH, CTSK, DCN, FBLN1, FHL1, FN, NKTR, OGN, PARVA, S100A6, SPARC, STC1 and ZEB1 proteins showed specific and varied expression patterns in fetal human prostate and in prostate cancer. Colocalization studies suggested that some stromally expressed molecules were also expressed in subsets of tumour epithelia, indicating that they may be novel markers of EMT. Additionally, two molecules (ASPN and STC1) marked overlapping and distinct subregions of stroma associated with tumour epithelia and may represent new CAF markers.

Role of androgens and fibroblast growth factors in prostatic development.

This review focuses on the role of androgens and fibroblast growth factors (FGFs) in regulating the growth and development of the prostate. It is known that androgens and mesenchymal-epithelial interactions are required for the formation and growth of the prostate, but little is known of the molecular mediators regulating prostatic organogenesis. Paracrine signalling from the mesenchyme to the epithelium is a key element of prostatic development and the action of androgens in mesenchymal cells is essential for prostatic development. This finding has led to the hypothesis that androgens regulate the expression of paracrine-acting growth factors. Although several families of growth factors play a role in regulating prostatic growth, the FGF family contains members that have been studied most comprehensively in regard to prostatic growth and branching morphogenesis. The role of FGFs in prostatic development is described in detail, since two members of the FGF family function as mesenchymal paracrine-acting factors in the prostate. It has been shown that FGF7 and FGF10 play important roles during prostatic development yet they do not appear to be regulated directly by androgens. Current models propose that growth factor expression (including FGF7 and 10) is regulated directly by androgens. However, it is possible that androgen regulation is indirect and a model outlining indirect androgen regulation of growth factors is proposed.

Prostatic growth and development are regulated by FGF10.

We have examined the role of Fibroblast Growth Factor 10 (FGF10) during the growth and development of the rat ventral prostate (VP) and seminal vesicle (SV). FGF10 transcripts were abundant at the earliest stages of organ formation and during neonatal organ growth, but were low or absent in growth-quiescent adult organs. In both the VP and SV, FGF10 transcripts were expressed only in a subset of mesenchymal cells and in a pattern consistent with a role as a paracrine epithelial regulator. In the neonatal VP, FGF10 mRNA was expressed initially in mesenchymal cells peripheral to the peri-urethral mesenchyme and distal to the elongating prostatic epithelial buds. At later stages, mesenchymal cells surrounding the epithelial buds also expressed FGF10 transcripts. During induction of the SV, FGF10 mRNA was present in mesenchyme surrounding the lower Wolffian ducts and, at later stages, FGF10 transcripts became restricted to mesenchymal cells subadjacent to the serosa. We investigated whether the FGF10 gene might be regulated by androgens by analysing the levels of FGF10 transcripts in SV and VP organs grown in serum-free organ culture. While FGF10 transcript levels increased after treatment with testosterone in the SV (but not VP), these changes were not sensitive to anti-androgen treatment, and thus it is likely that FGF10 mRNA was not directly regulated by testosterone. Also, FGF10 mRNA was observed in the embryonic female reproductive tract in a position analogous to that of the ventral prostate in males suggesting that FGF10 is not regulated by androgens in vivo. Recombinant FGF10 protein specifically stimulated growth of Dunning epithelial and BPH1 prostatic epithelial cell lines, but had no effect on growth of Dunning stromal cells or primary SV mesenchyme. Furthermore, FGF10 protein stimulated the development of ventral prostate and seminal vesicle organ rudiments in serum-free organ culture. When both FGF10 and testosterone were added to organs in vitro, there was no synergistic induction of development. Additionally, development induced by FGF10 was not inhibited by the addition of the anti-androgen Cyproterone Acetate demonstrating that the effects of FGF10 were not mediated by the androgen receptor. Taken together, our experiments suggest that FGF10 functions as a mesenchymal paracrine regulator of epithelial growth in the prostate and seminal vesicle and that the FGF10 gene is not regulated by androgens

Expression of the Wnt gene family during late nephrogenesis and complete ureteral obstruction.

Because the Wnt-4, -7b, and -11 genes are expressed in metanephric kidneys and code for secreted glycoproteins that may serve as mediators of the transformation of renal mesenchyme to epithelium, we investigated the pattern of Wnt gene expression in late metanephrogenesis and after ureteral obstruction. Newborn and 10-, 20-, and 60-day-old rats underwent complete unilateral ureteral ligation or sham operation. The kidneys were collected bilaterally 1, 5, 10, 20, or 30 days later. RNase protection assays were used to quantify the amounts of mRNA encoding Wnt-4, -7b, and -11, E-cadherin, and cytokeratin-19. Renal development was assessed by histologic characterization of vimentin, cytokeratin, E-cadherin, and beta-catenin distribution. During normal development, the amounts of mRNA encoding Wnt-4 and Wnt-11 increased during gestation and then abruptly decreased after the completion of metanephrogenesis, 15 days after birth. In contrast, the amounts of mRNA encoding Wnt-7b, E-cadherin, and cytokeratin-19 increased during development and into adulthood. In neonatally obstructed kidneys, the expression of Wnt-4 was abnormally maintained when obstruction was induced before the completion of renal development and was reactivated when obstruction was induced after the completion of metanephrogenesis. Wnt-7b expression was minimally affected and Wnt-11 expression was only transiently affected by obstruction. In neonatally obstructed kidneys, the differentiation of mesenchyme to epithelium failed to proceed normally, with the majority of cells maintaining vimentin expression and some differentiated epithelial cells reverting to vimentin expression. In addition, the expression of E-cadherin and cytokeratin was increased in epithelial cells. Changes in the expression of Wnt genes were correlated with histologic changes. This study suggests that Wnt-4 and -11 are likely to be important mediators of the transformation of mesenchyme to epithelium in the kidney. Obstruction induced during metanephrogenesis disrupts the normal pattern of Wnt-4, -7b, and -11 expression and interferes with the normal transformation process in developing kidneys, by maintaining the mesenchymal component and inducing the transformation of epithelium to mesenchyme.

Growth factor expression in the obstructed developing and mature rat kidney.

The purpose of this study is to evaluate the role of keratinocyte growth factor (KGF), transforming growth factor-alpha (TGF-alpha), and their receptors in altered renal growth caused by complete ureteral obstruction in the developing kidney. Neonatal and adult rats underwent complete unilateral ureteral ligation or sham operation. The kidneys were harvested at 1, 5, 10, 20, and 30 days after obstruction. Renal growth and development was assessed by histology and immunohistocytochemical localization of vimentin, cytokeratin and smooth muscle-alpha actin. Cellular proliferation was measured by [3H]thymidine labeling index of all cells. RNase protection assays were used to quantify mRNA encoding for KGF, KGF receptor, TGF-alpha, and epidermal growth factor (EGF) receptor. Ureteral obstruction in the developing kidneys resulted in decreased DNA synthesis, rapid parenchymal loss, myofibroblast proliferation in the interstitium, decreased tubular epithelial cells formation, and development of cystic dysplasia. In comparison, obstruction in the mature kidneys resulted in transient growth in the medullary ductal cells, parenchymal loss, and myofibroblast proliferation at a later time, lymphocytic infiltration in the interstitium but not cystic dysplasia. KGF and KGF receptor mRNA levels were increased in obstructed neonatal kidneys. Similarly, TGF-alpha and EGF receptor mRNA levels were increased. Delayed and more moderate increases in KGF, KGF receptor, and TGF-alpha expression were also seen in the obstructed mature kidneys. Of importance, the amount of EGF receptor mRNA was not increased in the obstructed compared with the contralateral or sham-operated adult kidneys. This study suggests that obstruction alters the normal expression pattern of KGF, TGF-alpha, and their receptors in renal development. These changes may be responsible for the impaired renal growth and altered development seen in ureteral obstruction of the kidneys. Although some changes are similar to those seen in the adult kidney, the increased expression of TGF-alpha and cystic dysplasia are unique to neonatal obstruction.

Keratinocyte growth factor injected into female mouse neonates stimulates uterine and vaginal epithelial growth.

Estradiol (E2) stimulates epithelial growth in the female genital tract via estrogen receptors (ER) in the stroma using paracrine mechanisms. Keratinocyte growth factor (KGF), a member of the fibroblast growth factor family, is produced by mesenchymal cells and is mitogenic for epithelial cells making it a strong candidate as a paracrine mediator. Transcripts for KGF and the KGF receptor were detected in the neonatal mouse uterus and vagina. Treatment of neonatal mice with KGF elicited changes in uterine and vaginal epithelium within five days and induced long term effects in these tissues. Newborn female Balb/c mice were injected daily with 5 microg/g body weight of KGF or saline for five days. KGF-treated mice exhibited a 5- to 6-fold increase in uterine epithelial BrdU-labeling index and a 4- and 5-fold increase in vaginal epithelial BrdU-labeling index vs. respective saline-treated controls. Histological sections of KGF-treated uteri revealed dramatic increases in epithelial surface area due to extensive folding of the luminal epithelium. In some areas, the evaginated luminal epithelium invaded zones normally occupied by myometrium. Vaginal epithelium was thicker than that of saline-treated controls following 5 days of KGF treatment. When KGF-treated newborn mice grew to adulthood and were ovariectomized, vaginal smears exhibited persistent diestrus in all animals. Histologic analysis demonstrated a thick parakeratotic vaginal epithelium (approximately 10 cell layers) 9 days postovariectomy in adult neonatally KGF-treated mice. Our studies indicate that KGF injected into neonates markedly stimulated proliferation of neonatal uterine and vaginal epithelium and elicited long-term, persistent abnormal changes in vaginal epithelium.

Enlargement of the ampullary gland and seminal vesicle, but not the prostate in int-2/Fgf-3 transgenic mice.

Expression of the int2/Fgf-3 gene occurs during normal embryonic development and is associated with mammary cancer in mice. Overexpression of this gene under the control of the mouse mammary tumor virus long terminal repeat (MMTV-LTR) in males was reported to result in prostatic enlargement. In this report male Fgf-3-overexpressing mice were shown to have enlarged ampullary glands, seminal vesicles, and ductus deferens; there was extensive epithelial hyperplasia in the ampullary glands and seminal vesicles. The prostates of these animals were of normal size and histology. The transgene was expressed in all of the enlarged organs, which are derived exclusively from the Wolffian duct. Male secondary sex organs derived from the urogenital sinus, e.g., the ventral prostate, coagulating gland, and bulbourethral glands, were normal and did not express the MMTV-LTR-driven Fgf-3 transgene. A dorsolateral prostate was also morphologically normal but did express the transgene. This study underscores the importance of careful organ identification in transgenic models in which gross organ enlargement or distortion occurs. It also highlights the heterogeneity of the response to Fgf-3 among the secondary sex organs and even within the prostate itself.

Cellular signaling in the bladder.

Embryologically, the urinary bladder is formed from endodermally derived epithelial cells and mesenchymal cells from the urogenital sinus and allantois. Experimentally, we have shown that bladder mesenchyme differentiates into bladder smooth muscle via an unknown signaling mechanism that originates from the urothelium. It is hypothesized that this signaling between the cellular types, occurs via growth factors. Evidence supporting this hypothesis is that a number of known growth factors, such as TGF beta 2 and 3, KGF and TGF alpha, as well as their receptors are regulated as a function of bladder development and are also modulated during experimental bladder outlet obstruction. Furthermore, growth factors most likely affect extracellular matrix degradative proteins which play a role in bladder remodeling during development, as well as in partial outlet obstruction. There is certainly impressive cellular communication that occurs during development and also occurs postnatally; such as during bladder injury. We have recently shown that KGF is directly responsible for the proliferation of urothelium during bladder injury. This normally quiescent cell, which in humans turns over once every six months to a year when injured, has the incredible ability to immediately proliferate covering the exposed areas of bladder muscle and submucosa. This proliferation is due to the direct effects of KGF, a classic paracrine growth factor which is secreted by the stromal compartment of the bladder and acts directly on the urothelium which harbors the receptor. The bladder also has an uncanny ability to regenerate. In a model to study the basic science behind bladder regeneration, a partial cystectomy was performed and an acellular tissue matrix devoid of all cellular elements was sutured to the defect. Within four days, the urothelium completely covered the acellular matrix, and within two weeks native smooth muscle was seen streaming into the acellular matrix in association with a new epithelium. It is hypothesized that cellular interactions between the epithelium and the mesenchyme, as we have shown in bladder differentiation, are encouraging the new growth of smooth muscle. For the bladder to be a safe and effective storage chamber the ideal cellular lining should be urothelium. Cells from the gastrointestinal are not optimal for this purpose since they either secrete or absorb electrolytes. We believe that the cellular interactions that occur between the urothelium and the foreign intestinal stroma will in time change the phenotype of the urothelium. Newer strategies for bladder replacement which take into account cellular signaling are critical for our young patients with neurogenic bladder disorders.

Analysis of growth factor and receptor mRNA levels during development of the rat seminal vesicle and prostate.

Development of the mammalian male accessory sexual organs requires both androgens and mesenchymal/epithelial interactions. Paracrine acting factors whose expression is mesenchymal and androgen dependent have been proposed to regulate development of these organs, although the identity of these paracrine mediators is unknown. Keratinocyte growth factor (Kgf) has been shown to play an important role in the development of the mouse seminal vesicle and rat ventral prostate. Also, Kgf is expressed in mesenchymal cells and has been shown to be regulated by androgens in prostatic cells grown in vitro. Thus Kgf has been proposed as a mediator of androgen action. We have investigated the expression of Kgf mRNA during development of the rat seminal vesicle and prostate, both in vitro and in vivo. Additionally we have examined mRNAs for Kgf receptor (KgfR), transforming growth factor alpha (Tgf alpha), epidermal growth factor receptor (EgfR) and cytokeratin 19 (CK19). The levels of growth factor and receptor mRNAs fluctuated during androgen-regulated development; however, these changes reflected variations in the mesenchymal/epithelial ratio rather than regulation by testosterone. Expression of Kgf is mesenchymal, while KgfR is epithelial and Tgf alpha is predominantly epithelial. The changes in the levels of mRNAs for these factors correlated well with changes in the level of an epithelial marker, CK19, suggesting they were due to alterations in the relative abundance of tissue compartments in which they were expressed. Kgf has been shown to mimic androgen action in explant cultures of seminal vesicle and prostate. We demonstrate here that anti-androgens are able to block Kgf stimulated development, suggesting that Kgf and androgen receptor signalling pathways may interact. Taken together our data suggest that, in vivo, Kgf may interact with androgen receptor signalling but it is not a direct target of androgen action.

Growth factors in bladder wound healing.

INTRODUCTION: Surgical and traumatic injuries to the bladder initiate a complex series of biological processes that result in wound healing. This process involves cellular proliferation, migration and differentiation; removal of damaged tissue; and production of extracellular matrix all of which may be controlled by growth factors. In skin, keratinocyte growth factor (KGF) is induced following incisional injury. We hypothesize that in bladder wound healing KGF and other growth factors are induced to modulate tissue repair. METHODS: We have created a model of surgical bladder injury in the rodent. At 12, 24 and 48 hrs and 5 and 7 days after injury, the bladder was bisected and total RNA extracted from the anterior or wounded half and posterior or non-wounded half. Histological analysis of the bladder wound was performed with Mason's Trichrome and immunohistochemistry against smooth muscle alpha actin. RNase protection assays were performed to examine the expression of KGF, transforming growth factor (TGF)alpha and TGF beta 2 and 3 as well as the receptors for KGF and epidermal growth factor (EGF). Lastly, the effects of the exogenous administration of KGF on the bladder was tested on neonatal mice by daily injections of 5 micrograms KGF per gram body weight for 5 days. RESULTS: At 12 hours after injury KGF mRNA expression in the anterior wounded bladder half and posterior non-wounded bladder half was 8 and 6 times higher respectively, compared to unoperated control bladders. A similar response was seen for TGF alpha, where the 12 hour mRNA expression was 4.5 times higher in the anterior wounded bladder half and 3.5 times higher in the posterior non-wounded bladder half compared to unoperated control bladders. The nadir mRNA expression for both KGF and TGF alpha occurred at 7 days after bladder injury and was the same as in unoperated control bladders. EGFR mRNA expression was approximately 2 times higher in both the anterior wounded and posterior non-wounded bladder halves compared to the nadir levels which occurred at 24 hours after injury. TGF beta 2 and beta 3 mRNA levels did not significantly change in either the anterior wounded or posterior non-wounded bladder halves. Exogenous KGF stimulation resulted in a marked urothelial proliferation when compared to age matched control animals. CONCLUSION: During the early phases of bladder wound healing (12-24 hours post injury), mRNA for KGF and TGF alpha increased, whereas TGF beta 2 and beta 3 and the KGFR and EGFR remain unchanged. Additionally, exogenous KGF has a direct effect on urothelial proliferation. KGF and TGF alpha warrant further study as potential mediators of bladder wound healing.

Growth factors and receptors in bladder development and obstruction.

During fetal and neonatal development and experimental obstruction, the bladder wall undergoes changes in both the amount and composition of the urothelium, extracellular matrix, and smooth muscle. We hypothesize that cell-cell signaling among the different layers of the bladder wall mediates these changes. Growth factors likely to be involved in this process are keratinocyte growth factor (KGF) and transforming growth factor (TGF)-alpha, -beta 2, and -beta 3. Whole rodent bladders were analyzed by RNase protection assays for KGF, KGF receptor, TGF alpha, epidermal growth factor receptor, and TGF beta 2 and -beta 3 transcripts at Fetal Day 14 (before smooth muscle differentiation) and Fetal Day 18 (after smooth muscle differentiation), at birth, and 60 days postnatal. Growth factor transcripts were also analyzed in partially obstructed rodent bladders and in sham-operated animals. TGF beta 2 and -beta 3 mRNA expression decreased as a function of gestational age, whereas TGF alpha mRNA increased. KGF mRNA was low before smooth muscle differentiation at 14 days' gestation, then increased. The mRNA of receptors for KGF and EGF remained essentially unchanged throughout bladder development. In bladders subjected to partial urethral outlet obstruction, there was a 2-fold increase in mRNA for TGF beta 2, a 5-fold increase in TGF beta 3, and a 10-fold increase TGF alpha mRNA. In contrast, there was no change in transcripts for either KGF or receptors for KGF and epidermal growth factor. Immunohistochemical localization of the protein for these growth factors showed selective localization to the epithelium and/or smooth muscle for TGF beta 2 and -beta 3, whereas TGF alpha and the epidermal growth factor receptor localized throughout the bladder wall. In conclusion, growth factor mRNA expression is modulated in bladder development and obstruction, which implies a possible mechanistic role of growth factors for the observed changes in the bladder wall and extracellular matrix.

Mesenchymal-epithelial interactions in the bladder.

During bladder development, undifferentiated mesenchymal and epithelial cells undergo an orderly sequence of differentiation defined by the expression of smooth-muscle (alpha-actin, myosin, vinculin, desmin, vimentin, and laminin) and epithelial (cytokeratins 5, 7, 8, 14, 18 and 19) protein markers. This process requires mesenchymal-epithelial interactions with bladder epithelium (urothelium) necessary for the differentiation of bladder smooth muscle. Peptide growth factors such as keratinocyte growth factor (KGF) and transforming growth factors (TGF) alpha and beta are likely candidates as mediators of these mesenchymal-epithelial interactions. Transcripts for KGF, TGF alpha, and TGF beta are regulated during bladder development and during smooth-muscle hypertrophy secondary to bladder-outlet obstruction. Finally, two experimental bladder models--(1) partial outlet obstruction and (2) regeneration of bladder smooth muscle into an acellular tissue matrix--are described in the context of mesenchymal-epithelial interactions in the bladder.

Sequences promoting the transcription of the human XA gene overlapping P450c21A correctly predict the presence of a novel, adrenal-specific, truncated form of tenascin-X.

A compact region in the human class III major histocompatibility locus contains the human genes for the fourth component of human complement (C4) and steroid 21-hydroxylase (P450c21) in one transcriptional orientation, while the gene for the extracellular matrix protein tenascin-X (TN-X) overlaps the last exon of P450c21 on the opposite strand of DNA in the opposite transcriptional orientation. This complex locus is duplicated into A and B loci, so that the organization is 5'-C4A-21A-XA-C4B-21B-XB-3'. Although this duplication event truncated the 65-kb X(B) gene to a 4.5-kb XA gene, the XA gene is transcriptionally active in the adrenal cortex. To examine the basis of the tissue-specific expression of XA and C4B, we cloned the 1763-bp region that lies between the cap sites for XA and C4B and analyzed its promoter activity in both the XA and the C4 orientations. Powerful, liver-specific sequences lie within the first 75 to 138 bp from the C4B cap site, and weaker elements lie within 128 bp of the XA cap site that function in both liver and adrenal cells. Because these 128 bp upstream from the XA cap site are perfectly preserved in the XB gene encoding TN-X, we sought to determine whether a transcript similar to XA arises within the XB gene. RNase protection assays, cDNA cloning, and RT/PCR show that adrenal cells contain a novel transcript, termed short XB (XB-S), which has the same open reading frame as TN-X.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult cystic fibrosis and the general surgeon.

We describe three adult patients who had cystic fibrosis and acute abdominal symptoms. In each case there were difficulties in diagnosis and treatment owing to the unfamiliarity of general surgeons with this disease. Successful management will depend on awareness of the entity of acute distal intestinal obstruction which may occur de novo in adult patients with cystic fibrosis.

The progesterone receptor can regulate transcription in the absence of a functional TATA box element.

We have investigated the importance of the TATA box element in the induction of transcription by the progesterone receptor. Transcription was analyzed from promoters containing a steroid response element upstream of a wild-type or mutated TATA box. Mutation of the TATA box resulted in a loss of correctly initiated transcripts and abolished binding of TATA factor to the TATA box in vitro but did not inhibit transcriptional activation by the progesterone receptor. Thus we conclude that the receptor is able to stimulate the rate of transcription in the absence of a functional TATA box.

A pattern of local recurrence following resection of colorectal cancer.

Twenty patients (10%) developed a local recurrence following 200 consecutive curative resections for colorectal carcinoma. Analysis of the pathology of the primary tumours suggests that invasion of adjacent tissues, and lymph node involvement, were more important presection on the mucosa. The average time interval between resection and diagnosis of local recurrence was 17 months. The average survival time following diagnosis was 10 months. Nineteen out of 20 of these patients developed evidence of disseminated disease subsequent to the diagnosis of local recurrence. The most effective palliation occurred in patients in whom the local recurrence could be resected.

Split cuff ileal stoma.

Long-term patient comfort after an ileal conduit urinary diversion depends on the conduit stoma. The problem of leak-proof urine collection of the flush stoma can be overcome by using a spout stoma but this could become stenotic unless everted. Eversion is a technically difficult procedure and produces a bulky spout that tends to prolapse. The use of carefully placed myotomies in the split cuff stoma described herein facilitates eversion and produces a slim stoma that accepts a compact, leak-proof appliance and is, at the same time, free of the complications of stenosis and prolapse in the long-term management.