ErbB2, ErbB3 and ErbB4 expression in urothelial tumors of the upper urinary tract and their prognostic significance.

PURPOSE: ErbB family represents a promising therapeutic target in upper urinary tract urothelial carcinoma (UUTUC). Our study aimed to correlate ErbB2, ErbB3 and ErbB4 expression in UUTUC with other clinicopathological parameters as well as patient outcome. METHODS: ErbB2, ErbB3 and ErbB4 were immunohistochemically assessed in 99 consecutive UUTUC specimens. RESULTS: With a median follow-up of 52.5 months (range 1-127) 28 patients (28.3%) died 1-95 months after the first surgical treatment and the mean survival was 18.9-24.2 months. ErbB2, ErbB3 and ErbB4 expression was positive in 64.8, 19.5, and 20.8% of the tumors, respectively. Combined expression of all 3 receptors was found in 7.9% of the tumors, combined expression of 2 receptors in 14.5% and 48.7% expressed at least one ErbB receptor. No ErbB expression was found in 28.9% of the tumors. We found no significant correlation between ErbB2, ErbB3 and ErbB4 expression with tumor stage, grade, recurrence or cancer specific survival apart from the inverse relation between ErbB2 expression and time to recurrence (p=0.027). CONCLUSION: Of the 3 receptors evaluated, neither ErbB3 nor ErbB4 showed any prognostic significance in the UUTUC. ErbB2, however, was inversely associated with recurrence and needs further evaluation in well-designed, prospective, randomized trials.

Evaluation of flap valve as an alternative continence mechanism in the Florida pouch.

OBJECTIVES: To evaluate urodynamic findings in a successful flap valve (FV) continence mechanism in association with a continent colonic urinary reservoir (Florida pouch) and to compare the urodynamic findings of the FV mechanism with the doubly plicated (PI) standard anti-incontinence segment in the same reservoir. METHODS: Thirteen patients who successfully received the Florida pouch between 1988 and 1996 agreed to undergo urodynamic evaluation as part of a pilot study. Eight patients had a PI continence mechanism and a mean time from surgery of 51 months; 5 had a FV continence mechanism and a mean time from surgery of 14 months. Enterocystometry was performed with a trans-stomal Bard triple channel 7F catheter. Volume and pressure at first desire to empty (VFDE, PFDE), as well as maximal enterocystometric capacity and pressure (VMEC, PMEC), were recorded. Maximal outlet pressure (MOP) was recorded using the catheter withdrawal technique. RESULTS: PI and FV groups demonstrated the following mean values respectively: VFDE, 692.7 and 403 mL; PFDE, 19.5 and 19.2 cm H2O; VMEC, 876.5 and 515 mL; PMEC, 25.9 and 24.6 cm H2O; MOP, 57.5 and 51.2 cm H2O (reservoir empty) and 50.5 and 52.6 cm H2O (reservoir full); and functional length of outlet, 24.3 and 24.6 cm. MOP measurement demonstrated greater variability in the PI than in the FV group. CONCLUSIONS: Urodynamic comparison of these mechanisms reveals that MOP measurement was closer to the mean among FV than PI patients. In addition, the mean VFDE (692.7 mL for PI versus 403 mL for FV, P < 0.05) and the mean VMEC (876.5 mL for PI versus 515 mL for FV, P < 0.05) were significantly less in the FV group. Lower VMEC and less variability in MOP indicate that continence may be more dependent on MOP in the FV mechanism. A longer follow-up time and a larger number of patients will be of assistance in clarifying these findings.

Evaluation and management of parastomal hernia in association with continent urinary diversion.

PURPOSE: We discuss the incidence and diagnosis of parastomal hernias in association with continent urinary reservoirs. We also present a surgical technique appropriate for correction of this complication. MATERIALS AND METHODS: We evaluated 21 patients with parastomal hernia after construction of a continent urinary reservoir. The hernia developed secondary to diversion with an ileocecal segment in 19 patients and a Kock procedure in 2. Subsequent to development of the parastomal hernia 13 patients (61.9%) had simultaneous urinary incontinence, 2 (9.5%) had difficulty catheterizing the reservoir and 4 (19.047%) had associated pain over the stomal area. Evaluation was primarily by physical examination. However, 2 patients (9.5%) required abdominal computerized tomography to confirm the diagnosis of parastomal hernia. Surgical repair was recommended for all patients, and 19 underwent repair with or without revision of the anti-incontinence segment. Reconstruction included transabdominal takedown of the anti-incontinence segment from the abdominal wall with parastomal hernia closure through a midline incision, external reinforcement of the hernia opening with Marlex mesh when the diameter exceeded 6 cm., revision of the anti-incontinence mechanism when simultaneous urinary incontinence existed preoperatively and repositioning of the stoma site through a new selected area in the abdominal wall. RESULTS: The success rate (mean followup 23.4 months) with this surgical approach was 89.5%. Incontinence due to failure of the anti-incontinence mechanism was successfully corrected in 13 patients (100%). CONCLUSIONS: Long-term followup of continent urinary reservoirs is often associated with development of parastomal hernia. This complication can be associated with urinary incontinence, peristomal pain and difficult catheterization. Evaluation is primarily by physical examination but selected clinical situations require abdominal computerized tomography to confirm the diagnosis. The surgical technique following the steps described has been associated with minimal morbidity and has provided excellent surgical results (89.5% success rate).

The failed anti-incontinence mechanism: a flap valve or cecal wrap for surgical reconstruction.

PURPOSE: On a long-term basis patients with continent urinary diversions may have an acceptable number of complications, such as urinary incontinence. We report on a new surgical technique for treatment of the incompetent anti-incontinence segment. MATERIALS AND METHODS: Seven patients presented with a large capacity, low pressure reservoir and an incompetent anti-incontinence mechanism. The original anti-incontinence mechanism consisted of an intussuscepted reimplanted appendix (Mitrofanoff) in 2 patients, tapered ileum and reinforced ileocecal valve in 3, and tapered and reimplanted ileal segment in 2. Surgical reconstruction involved 2 stages: stage 1 - lengthening and tubularizing the cecum with the anti-incontinence segment and stage 2 - creation of the flap valve mechanism. Stage 2 required intraoperative modification when abundant peri-reservoir fibrosis, a thin-walled reservoir (cecal wrap) or an excessive thickened mesentery was encountered. RESULTS: After a mean followup of 7 months 6 of 7 patients performed catheterization every 4 hours and were continent. Several patients required a concomitant procedure with the incontinence revision. CONCLUSIONS: We describe a 2-stage technique for correction of a variety of untoward anatomical conditions related to a failed anti-incontinence segment with continent urinary reservoirs. Concomitant repair of other coexisting structural abnormalities related to the continent reservoir may also be necessary.

Bladder Replacement and Urinary Diversion After Radical Cystectomy.

BACKGROUND: The optimal mode of urinary tract reconstruction following cystectomy continues to challenge the urologic surgeon. Disadvantages with bowel conduits have prompted the search for better techniques to improve patient outcomes. METHODS: The development of urinary tract reconstruction is reviewed, and results from several forms of continent urinary diversion and bladder replacement construction are presented. The authors report on their experience in creating continent reservoirs or neobladders in over 400 patients. RESULTS: Several surgical approaches are now available for continent urinary diversion. Metabolic and nutritional abnormalities, stone formation, infection, and cancer formation are potential complications. CONCLUSIONS: Advances in surgical techniques, an understanding of the physiology of isolated bowel segments, and improvements in pre- and post-operative care have altered the field of urinary reconstruction after cystectomy for bladder cancer. Most patients can expect minimal morbidity and mortality.

Urethral obstruction after anti-incontinence surgery in women: evaluation, methodology, and surgical results.

OBJECTIVES: To evaluate a group of women with voiding dysfunction and a low maximum flow rate (MFR) (less than or equal to 12 mL/s) after surgery for stress urinary incontinence (SUI); to establish diagnostic parameters indicating obstruction in an attempt to determine treatment selection; and to evaluate preliminary surgical results. METHODS: Eighteen women who underwent anti-incontinence surgery for SUI were diagnosed as having infravesical obstruction (IO). Thirteen women (group A [72%]) presented with clinically predominant symptoms of urgency, frequency, intermittency, and a variable vesical residual volume (RV), and five (group B [28%]) had as their most significant symptoms a high vesical RV and urinary tract infection that had been managed with intermittent catheterization (IC). The diagnosis of IO, suspected after clinical history, was established after physical examination and cystoscopic, cystographic and urodynamic investigations. RESULTS: Bladder instability was demonstrated in 6 group A patients (46%) and 1 group B patient (20%) (P = NS). Mean MFRs were 8.07 and 7.2 mL/s, respectively, in both groups (P = NS). Mean maximal voiding pressures (MVPs) were 20.23 and 5 cm H20, and mean RVs were 57.46 and 174 mL, respectively; both differences were statistically very significant (P <0.01 and P <0.001, respectively). High to normal MVPs occurred in 2 patients overall (11%). Bladder neck overcorrection, midurethral distortion, and postsurgical cystocele were demonstrated in both groups in 11 (85%), 0, and 2 (15%) patients in group A and 3 (60%), 2 (40%), and 3 (60%) patients in group B, respectively (P = NS). Patients in group A were treated surgically with cystourethrolysis and a repeated, less obstructive anti-incontinence operation. In group B 2 women (40%) had a similar surgical procedure; 1 (20%) underwent isolated urethrolysis; and 2 (40%) are currently maintained with IC. CONCLUSIONS: Among these 18 patients with voiding dysfunction after anti-incontinence surgery, a primary diagnosis of IO was established clinically. Only patients with a low MFR were selected for this study. Cytographic and endoscopic investigation as well as the presence of postsurgical cystocele assisted in establishing the diagnosis. The success rate with urethrolysis and resuspension was 60% for the 13 women with predominantly urgency, frequency, and the highest MVPs (20.23 +/- 9.67 cm H20 [group A) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group A]) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group B]). An added resuspension procedure is probably unnecessary in the latter group of patients and requires careful individual selection in the former group.

Changes in cerebrospinal fluid enzyme activity after severe head injury. Diagnostic and prognostic values.

We studied CSF CK and LDH isoenzyme activities in 27 patients with severe head injury and in 10 patients with chronic hydrocephalus not related to trauma. CSF enzymes showed an increased activity immediately after trauma, contrasting with the low values measured in the patients with hydrocephalus. In severe head injury, we found a correlation between enzyme release and brain dysfunction assessed according to two methods: the Glasgow coma scale (GCS), and the Liège coma scale (LCS) which uses elements of the GCS and the study of 5 brain stem reflexes. The correlation between enzyme activity and the Liège coma scores is better than that observed with the Glasgow coma scores. High enzyme activity is associated with a bad outcome at six months. It has a prognostic value on so far as it reflects the severity of traumatic structural brain damage.

Diabetic osteopathy of the foot and ankle.

Neuropathic osteopathy of the foot and ankle is almost always due to underlying diabetes mellitus. The "Charcot joint," or destructive type, affects the ankle or tarsal area, and the "bone absorption," or mutilating type, usually affects the forefoot. If both types are present in the feet, it is almost certain that the patient is a diabetic. While these findings are usually seen in patients with long-standing, poorly controlled diabetes, they may be the first indication of diabetes.

Neurogenic disorders of the foot in diabetes mellitus.

Neurogenic disorders of the foot in diabetics have been found with increasing frequency in recent years, Therefore, familiarity with the spectrum of roentgen findings appears essential. Significant changes include Charcot joints of the tarsus (destructive type), and bone absorption of the forefoot (multilating type). Charcot joints have been observed in 11 patients, bone absorption in 12, and a combination of both types in 3. This combination strongly suggests a diabetic neuropathy. Pathogenesis and differential diagnosis are briefly discussed.