The use of ileocecal pouch with appendix as an urethral substitute in patients who are willing to have a orthotopic bladder replacement - point of technique.

INTRODUCTION: The authors describe the technique of orthotopic bladder replacement with an ileocecal pouch and unaltered appendix used as an orthotopic urethral substitute. Additional procedures with regard to the bothersome voiding symptoms will be described. MATERIAL AND METHODS: In a small cohort of 5 patients with muscle invasive bladder cancer with tumor involvement of the bladder neck or proximal urethra (2 males/3 females) we performed the following reconstruction. A low pressure reservoir was achieved by antimesenteric longitudinal transection of terminal ileum and cecum/colon ascendens and formation of a pouch. To develop the neourethra, the appendix together with it is accompanying mesentery was drawn through the pelvic floor and sutured to the bulbar urethra in males or formed as a complete neourethra in female patients respectively. RESULTS: There were no intraoperative nor early postoperative unwanted sequelae. Both male patients experienced recurrent anastomotic urethral stricture, consequently a Memokath stent and artificial urinary sphincter was implanted resulting in normal voluntary micturition. All female patients remained socially continent during the follow up period, one of them performing (clean intermittent catheterization) CIC. CONCLUSION: The technique described offers the possibility of orthotopic bladder replacement even in traditionally unsuitable, but highly motivated patients, who are requesting orthotopic bladder replacement for improved body image. It allows extension of urethral resection and provides additional continence support. However, additional measures such as urethral stenting, CIC or artificial urinary sphincter implantation may be necessary for long lasting success. Although, not being a routine method for urinary diversion this technique may be used in select patients.

Bolsa ileocecal con utilización del apéndice como neouretra en pacientes dispuestos a sustitución vesical ortotópica: descripción de la técnica / The use of ileocecal pouch with appendix as an urethral substitute in patients who are willing to have a orthotopic bladder replacement - point of technique

Introducción: Los autores describen la técnica de sustitución vesical ortotópica mediante bolsa ileocecal y apéndice inalterado como sustituto ortotópico de la uretra. Se describirán procedimientos adicionales con respecto a las molestias por síntomas de vaciado.Material y métodosEn una pequeña cohorte de 5 pacientes con cáncer de vejiga musculoinvasivo con afectación tumoral del cuello vesical o de la uretra proximal (2 hombres/3 mujeres) realizamos la siguiente reconstrucción. Se obtuvo un reservorio de baja presión mediante la incisión longitudinal antimesentérica del íleon terminal y el ciego/colon ascendente y la formación de una bolsa. Para desarrollar la neouretra, el apéndice y su mesenterio se extrajeron a través del suelo pélvico y se suturó a la uretra bulbar en los hombres o se formó como una neouretra completa en las mujeres, respectivamente.ResultadosNo hubo secuelas indeseables intraoperatorias ni postoperatorias tempranas. Ambos pacientes masculinos experimentaron una estenosis de la anastomosis uretral recurrente, por lo que se realizó un implante de stent Memokath y un esfínter urinario artificial, resultando en una micción voluntaria normal. Todas las pacientes femeninas permanecieron socialmente continentes durante el período de seguimiento, una de ellas realizando cateterismo intermitente limpio (CIL).ConclusiónLa técnica descrita ofrece la posibilidad de la sustitución vesical ortotópica incluso en pacientes tradicionalmente considerados como no aptos, pero muy motivados, que lo solicitan para mejorar su imagen corporal. Permite ampliar la resección uretral y proporciona un apoyo adicional a la continencia. Sin embargo, pueden ser necesarias medidas adicionales como la colocación de un stent uretral, el CIL o el implante de un esfínter urinario artificial para obtener un éxito duradero. Aunque no es un método rutinario de derivación urinaria, esta técnica puede utilizarse en pacientes seleccionados. (AU)

Introduction: The authors describe the technique of orthotopic bladder replacement with an ileocecal pouch and unaltered appendix used as an orthotopic urethral substitute. Additional procedures with regard to the bothersome voiding symptoms will be described.Material and methodsIn a small cohort of 5 patients with muscle invasive bladder cancer with tumor involvement of the bladder neck or proximal urethra (2 males/3 females) we performed the following reconstruction. A low pressure reservoir was achieved by antimesenteric longitudinal transection of terminal ileum and cecum/colon ascendens and formation of a pouch. To develop the neourethra, the appendix together with its accompanying mesentery was drawn through the pelvic floor and sutured to the bulbar urethra in males or formed as a complete neourethra in female patients respectively.ResultsThere were no intraoperative nor early postoperative unwanted sequelae. Both male patients experienced recurrent anastomotic urethral stricture, consequently a Memokath stent and artificial urinary sphincter was implanted resulting in normal voluntary micturition. All female patients remained socially continent during the follow up period, one of them performing clean intermittent catheterization (CIC).ConclusionThe technique described offers the possibility of orthotopic bladder replacement even in traditionally unsuitable, but highly motivated patients, who are requesting orthotopic bladder replacement for improved body image. It allows extension of urethral resection and provides additional continence support. However, additional measures such as urethral stenting, CIC or artificial urinary sphincter implantation may be necessary for long lasting success. Although, not being a routine method for urinary diversion this technique may be used in select patients. (AU)

Tratamiento de la lesión uretral cistoscópica iatrogénica asociada a secuela de la erosión del manguito en un paciente después de la implantación previa de AMS 800. Técnica de un solo paso con revisión, sin explantación del manguito / Management of iatrogenic cystoscopic urethral lesion associated with sequela of cuff erosion in a patient after previous AMS 800 implantation. One-step technique with revision, without cuff explantation

Introducción: La lesión uretral iatrogénica con posterior erosión del manguito durante la cistoscopia es una complicación poco frecuente. Se presentará la estrategia quirúrgica alternativa con uretroplastia in situ manteniendo el manguito abierto in situ. Materiales y métodos: Los autores describen 3 casos de lesión uretral iatrogénica con erosión del manguito durante la evaluación cistoscópica para excluir la estenosis o la erosión del manguito debido a la reaparición de síntomas obstructivos del tracto urinario inferior. Todos los pacientes tenían antecedentes de implantación de AMS 800 por incontinencia posprostatectomía. Se realizó una cistoscopia rígida, que no reveló alteraciones; sin embargo, se identificó una pequeña lesión uretral iatrogénica durante la extirpación del cistoscopio en la proyección del manguito. Resultados: Se realizó uretroplastia in situ y el manguito se dejó abierto in situ. Además, se colocó una solapa de grasa protectora alrededor de la uretra desde la cara dorsolateral, separando el manguito y la uretra del contacto directo entre sí. Después de 6 semanas el defecto uretral se curó completamente y a través de una incisión perineal primaria el manguito fue readaptado y cerrado. El dispositivo estaba funcionando sin ningún ajuste adicional. Conclusión: Nuestra modificación debe considerarse, en casos seleccionados sin infección, como parte de la estrategia de tratamiento en los casos de lesiones uretrales iatrogénicas con posterior erosión del manguito. De esta manera se puede evitar el manguito original y la preparación posiblemente difícil de la uretra durante la reoperación. Sin embargo, se deben presentar más casos en la literatura mundial para confirmar la utilidad de este principio quirúrgico

Introduction: Iatrogenic urethral lesion with subsequent cuff erosion during cystoscopy is a rare complication. The alternative surgical strategy with in situ urethroplasty while maintaining the open cuff left in situ will be presented. Materials and methods: The authors report 3 cases of iatrogenic urethral lesion with cuff erosion during cystoscopic evaluation to exclude stricture or cuff erosion due to new onset of obstructive lower urinary tract symptoms. All patients had a history of a AMS 800 implantation due to posprostatectomy incontinence. Rigid cystoscopy was performed, which revelaed no pathologies; however, iatrogenic small urethral lesion was identified during the removal of the cystoscope at the projection of the cuff. Results: In situ urethroplasty was performed, and the cuff was left open in situ. Additionally a protection fat flap was placed around the urethra from the dorsolateral aspect, separating the cuff and urethra from the direct contact with each other. After 6 weeks the urethral defect was completely healed and via a primary perineal incision the cuff was readapted and closed. The device was fully functioning without any additional adjustments. Conclusion: Our modification should be considered in select cases with absence of infection as part of management strategy for cases of iatrogenic urethral lesions with subsequent cuff erosion. Thereby the original cuff can be spared and the possibly difficult preparation of the urethra during reoperation can be avoided. However, additional more cases should be presented in the world-wide literature, to confirm the utility of this surgical principle

Urinary fluorescence analysis in diagnosis of bladder cancer.

Early diagnosis of bladder cancer is crucial for improvement of cancer specific survival and recurrence rate. We analyzed the possible role of fluorescence urine analysis in bladder cancer diagnosis. The cohort consisted of 20 healthy controls, 40 patients with hematuria and 75 patients with hematuria and histologically proven bladder tumor. Synchronous fluores- cence spectra with a 70 nm wavelength difference were recorded for (1:1-1:128) urine dilutions. Concentration matrices of synchronous spectra (CMSS) were used to classify samples into tested groups. CMSS analysis allowed us to distinguish patients with tumor from patients with hematuria with a sensitivity 55% and specificity 74.7%. This is comparable to the sensitivity and specificity of other non-invasive tests like BTA stat and nmP-22 (Bladder check®). Lower fluorescence inten- sity of Imax 280 nm and ratio of 280 nm to 450 nm was found to be associated with the presence of tumor. We have found an association of decreased fluorescence with the stage of the disease. Our data suggest that CMSS urine analysis has a potential role in the non-invasive diagnostic tests for bladder cancer, but it cannot replace the current diagnostic algorithm yet.

Management of iatrogenic cystoscopic urethral lesion associated with sequela of cuff erosion in a patient after previous AMS 800 implantation. One-step technique with revision, without cuff explantation. / Tratamiento de la lesión uretral cistoscópica iatrogénica asociada a secuela de la erosión del manguito en un paciente después de la implantación previa de AMS 800. Técnica de un solo paso con revisión, sin explantación del manguito.

INTRODUCTION: Iatrogenic urethral lesion with subsequent cuff erosion during cystoscopy is a rare complication. The alternative surgical strategy with in situ urethroplasty while maintaining the open cuff left in situ will be presented. MATERIALS AND METHODS: The authors report 3cases of iatrogenic urethral lesion with cuff erosion during cystoscopic evaluation to exclude stricture or cuff erosion due to new onset of obstructive lower urinary tract symptoms. All patients had a history of a AMS 800 implantation due to posprostatectomy incontinence. Rigid cystoscopy was performed, which revelaed no pathologies; however, iatrogenic small urethral lesion was identified during the removal of the cystoscope at the projection of the cuff. RESULTS: In situ urethroplasty was performed, and the cuff was left open in situ. Additionally a protection fat flap was placed around the urethra from the dorsolateral aspect, separating the cuff and urethra from the direct contact with each other. After 6 weeks the urethral defect was completely healed and via a primary perineal incision the cuff was readapted and closed. The device was fully functioning without any additional adjustments. CONCLUSION: Our modification should be considered in select cases with absence of infection as part of management strategy for cases of iatrogenic urethral lesions with subsequent cuff erosion. Thereby the original cuff can be spared and the possibly difficult preparation of the urethra during reoperation can be avoided. However, additional more cases should be presented in the world-wide literature, to confirm the utility of this surgical principle.

Utility and limitations of 3-Tesla diffusion-weighted magnetic resonance imaging for differentiation of renal tumors.

OBJECTIVE: To investigate utility and limitations of 3-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for differentiation of benign versus malignant renal lesions and renal cell carcinoma (RCC) subtypes. MATERIALS AND METHODS: Sixty patients with 71 renal lesions underwent 3 Tesla DW-MRI of the kidney before diagnostic tissue confirmation. The images were retrospectively evaluated blinded to histology. Single-shot echo-planar imaging was used as the DW imaging technique. Apparent diffusion coefficient (ADC) values were measured and compared with histopathological characteristics. RESULTS: There were 54 malignant and 17 benign lesions, 46 lesions being small renal masses ≤ 4 cm. Papillary RCC lesions had lower ADC values (p=0.029) than other RCC subtypes (clear cell or chromophobe). Diagnostic accuracy of DW-MRI for differentiation of papillary from non-papillary RCC was 70.3% resulting in a sensitivity and specificity of 64.3% (95% CI, 35.1-87.2) and 77.1 (95% CI, 59.9-89.6%). Accuracy increased to 83.7% in small renal masses (≤ 4 cm diameter) and sensitivity and specificity were 75.0% and 88.5%, respectively. The ADC values did not differ significantly between benign and malignant renal lesions (p=0.45). CONCLUSIONS: DW-MRI seems to distinguish between papillary and other subtypes of RCCs especially in small renal masses but could not differentiate between benign and malignant renal lesions. Therefore, the use of DW-MRI for preoperative differentiation of renal lesions is limited.

Incidence of balanitis xerotica obliterans in boys younger than 10 years presenting with phimosis.

OBJECTIVE: Evaluation of the true incidence of balanitis xerotica obliterans (BXO) among boys younger than 10 years. METHODS: In a period of 13 months, 75 boys younger than 10 years were treated for phimosis. Suspicion of BXO was raised in phimosis grade 2 or 3 (classification by Kikiros). Patients were offered primarily either circumcision or conservative therapy and circumcision secondarily (if treatment failed in the conservative group). Each circumcision specimen was examined histopathologically. RESULTS: Circumcision was primarily performed in 29 and secondarily in 17 patients. The mean age was 3.7 years (range 1-10). BXO, chronic inflammation, and normal histological results were found in 8/26/12 (17.4/56.5/26.1%) cases, respectively. The mean follow-up was 8.1 months. No recurrences were reported. CONCLUSIONS: The incidence of BXO appears to be higher than previously reported. The clinical appearance in children may be confusing. The preoperative BXO suspicion did not correlate with the final histopathological results.

Critical appraisal of prognostic factors for transobturator tape implantation.

OBJECTIVES: The aim of the study was (1) to compare early results of transobturator tape (TOT) implantation in women with lower and higher Valsalva leak point pressure (VLPP) and (2) to find out significant and independent prognostic factors of TOT implantation. MATERIAL AND METHODS: 97 female patients (pts) underwent TOT implantation between March 2004 and September 2007. We observed preoperative parameters including VLPP, urine leakage (PWT1), quality of life (IQOL1), age, BMI, parity, previous anti-incontinence surgery, hysterectomy status (HYE) and symptoms of OAB. According to VLPP value, pts were divided into two groups, namely those with lower VLPP values (< or =60 cmH2O) and those with higher VLPP values (> 60 cmH2O). Two different tapes were used for TOT implantation (resorbable and non-resorbable). Six months after surgery, urine leakage (PWT2) was reassessed and pts were classed into two main categories as 'cured' (PWT2 < or =2 g), or 'not cured' (PWT2 >2 g). RESULTS: Pts with lower VLPP values had significantly lower cure rates than those with higher VLPP values (43.8% vs. 81.5%, p < 0.001, respectively). Univariate logistic regresion analysis identified VLPP, PWT1, IQOL1, age, HYE, and TOT type parameters as significant factors for cure. Of these significant parameters, the multivariate logistic regresion analysis identified PWT1 and TOT type as the only independent ones. CONCLUSIONS: Pts with lower VLPP values are at a five-fold greater risk of not being cured than those with higher VLPP values. Preoperative urine leakage and TOT type are the only independent prognostic factors for cure after TOT implantation (Tab. 5, Fig. 3, Ref. 32).

Spontaneous regression of complex cystic renal mass of bosniak class IV--a rare phenomenon.

Spontaneous remission of simple renal cyst or complex renal cyst Bosniak III or IV class is a rare phenomenon. Our report describes a spontaneous partial regression of complex renal cyst Bosniak IV during the observation of complex cystic renal masses. A 66 year old male high risk patient (ASA score 3-4) refused all surgical intervention and was suggested for active surveillance strategy. We observed spontaneous partial regression of the complex cyst in this patient. To our knowledge this is the first report of spontaneous partial regression of complex renal cyst Bosniak IV class (Fig. 3, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

Enterovesical fistulas in Crohn's disease.

BACKGROUND: Crohn's disease is a chronic inflammatory disease of the bowel, that may affects the urinary system. Although fistula formation has been reported in up to 35% patients suffering from Crohn's disease, urinary fistulas affect only 2 to 8% patients. PATIENTS AND METHODS: Authors have done a retrospective study with the aim to investigate the incidence of enterovesical fistulas in patients admitted due to Crohn's disease to the IInd Department of Surgery of the Comenius University Medical School and Department of Surgery of University Hospital Nitra during 10 years long period. RESULTS: The overall incidence of enterovesical fistulas in our clinical material was 6.83%. All patiens underwent elective surgery. There were no serious postoperative complication. A two stage approach was necessary due to severe inflammation in one patient. Severity of inflammation decreased later on, after treatment with anti TNF *, which allowed subsequent elective surgery. CONCLUSION: Authors consider elective surgery as a treatment of choice in the managenet of enterovesical fistulas in Crohn's disease. Surgery is effective and safe (Fig. 2, Ref. 3). Full Text (Free, PDF) www.bmj.sk.

Cystic renal cell carcinoma--rare clinical finding. Radiographic variations of tumor/cyst appearance and further diagnostic work-up.

OBJECTIVES: To review the cases of cystic renal cell carcinoma and multilocular cystic nephroma, point out the radiographic variations and define further diagnostic work-up. MATERIALS AND METHODS: Between 2003 and 2005 5 patients with suspected cystic renal cell carcinoma were treated surgically (1 pt underwent radical nephrectomy, 1 pt laparoscopic cyst decortication, 3 pts ablation), 2 patients with multilocular cystic nephroma underwent ultrasound guided biopsy. RESULTS: Histopathologic examination confirmed cystic renal cell carcinoma (CRCC) T1aNOM0 Fuhrman grade 1 in 3 cases, T1bN0M0 Fuhrman grade 2 in one case. One patient with suspected tumor inside the cyst wall who underwent laparoscopic cyst decortication was excluded (final histology confirmed organized hematoma in the cyst wall). Biopsy in 2 patients with multilocular cystic nephroma did not confirm the presence of malignant cells. The mean tumor size was 4.2 cm (range 3.7 to 5.5) for CRCC and 4.7 cm (range 4 to 4.5 cm) for multilocular cystic nephroma. All 4 cases of CRCC were clear cell type. CONCLUSION: In conclusion according to the data described and from our study, tumor/cyst co-existence requires further surgical exploration in group 2, 3, 4. Small cystic renal cell carcinomas up to 4 cm in diameter have usually favourable pathology and prognosis, which offers the minimally invasive nephron-sparing treatment options such as excision, ablation or partial nephrectomy (Fig. 9, Ref. 18).

Valsalva leak point pressure predicts outcome after transobturator suburethral tape implantation--fact or fiction?

INTRODUCTION AND OBJECTIVES: The aim of the study was to assess the influence of Valsalva leak point pressure (VLPP) on outcome of transobturator suburethral tape (TOT) implantation. MATERIAL AND METHODS: 65 female patients underwent surgery between March 2004 and November 2005. Their inclusion criterion was urodynamic stress urinary incontinence (SUI). The exclusion criteria were detrusor overactivity, detrusor underactivity, a significant post-void residuum and genital prolapse. "Subjective improvement" was considered as the difference between postoperative urinary-incontinence specific quality of life compered with its preoperative value (deltaIQoL=IQoL*-IQoL). RESULTS: Postoperative leakage and postoperative urinary incontinence specific quality of life in 1st versus 2nd group were 1.2+/-1.1 g and 90.6+/-5.1 versus 4.6+/-3.1 g and 84.0=5.6 respectively (p<0.005 and p<0.005 respectively). CONCLUSIONS: Cure and success rates were significantly higher in patients with higher VLPP values compared with patients with lower VLPP values. In spite of the fact that patients with higher VLPP values achieved significantly lower postoperative leakage, urine leakage decreased significantly more in patients with lower VLPP values. Patients with higher VLPP values reached significantly higher postoperative urinary incontinence-specific quality of life, however no significant difference was found in subjective improvement between patients with higher and lower VLPP values (Tab. 1, Ref. 23).

Retroperitoneoscopic approach in the treatment of symptomatic renal cysts.

INTRODUCTION AND OBJECTIVE: The authors present the results and follow up of patients with simple parenchymal and peripelvic cysts who underwent retroperitoneoscopic cyst decortication. MATERIAL AND METHODS: The records of 19 patients who underwent 3/4-port retroperitoneoscopic cyst decortication between January 1999 and January 2004 were retrospectively reviewed. All patients admitted to the hospital were symptomatic, the most common presenting syptoms were flank pain (19p) and hematuria (6p). The cyst size ranged from 8 to 15cm (mean size 10cm). 10 cysts were located on the right kidney and 9 cysts on the left kidney. The mean age of patients was 51 years. 16 patients had a simple parenchymal cyst corresponding to Bosniak type I (8 patients underwent cyst aspiration and sclerotherapy with 96 % alcohol in past), 2 patients had peripelvic cyst corresponding to Bosniak type II and 1 patient had a parenchymal cyst Bosniak type II. RESULTS: Retroperitoneoscopic renal cyst decortication was successfully performed in all patients, no conversion was needed. The mean operative time was 70 min (50-90 min) in patients with parenchymal and peripelvic cysts. The mean operative blood loss was 70 ml (50-130 ml) and the mean lenght of hospital stay was 3 days (2-5 days). The follow up ranged from 6 to 48 months and during that period were all patients asymptomatic, with no signs of recurrence. CONCLUSIONS: Retroperitoneoscopic cyst decortication is a safe and effective operative procedure in the treatment of symptomatic renal cysts with the minimal complication rate and excellent results (Tab. 2, Fig. 3, Ref. 30).

Epicystoscopic approach in the treatment of foreign body in the urethra and urinary bladder.

In most cases the foreign body can be removed transurethrally with a pair of grasping forceps. In some cases objects have to be cut or resected into small fragments, making it easier to extract the object or wash it out. An open surgical procedure via suprapubic transvesical approach is reserved for large-sized bodies or in cases when endoscopic methods are unsuccessful. The laparoscopic removal is one of further techniques that provide the opportunity to untie the knots (Fig. 6, Ref. 6).

Renal autotransplantation in irreversible ureteral injury.

The authors describe a case of ureteral avulsion in ureteroscopy and extraction of calculus from the central part of the ureter. They chose a renal autotransplantation for the ureter reconstruction. They share the same opinion as the authors who use renal autotransplantation as the method of choice in irreversible ureteral injury. Ureteral avulsion is the most severe complication of ureteroscopy. The authors described a case of right ureteral avulsion, with subsequent autotransplantation as the final solution. (Fig. 6, Ref. 7.).