Review of continent urinary diversion in contemporary urology.

Continent urinary diversion (CUD) continues to be widely accepted by both urologists and patients for urinary reconstruction after cystectomy and some complicated cases of urinary incontinence. Different operative techniques and modifications have been contributed in the last 3 decades. The advantages and disadvantages of each technique have long been debated. Ureterosigmoidostomy is the oldest form of CUD but has lost favor in recent decades. The other 2 broad categories of CUD are cutaneous and orthotopic CUD. This review presents and discusses the current common forms of continent urinary diversions.

Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor necrosis factor inhibitors.

BACKGROUND: Rheumatoid arthritis (RA) and periodontitis are common chronic inflammatory conditions. Recent studies showed a beneficial effect of periodontal treatment on the severity of active RA. This study was undertaken to further examine the effect of non-surgical periodontal treatment on the signs and symptoms of RA in patients treated with or without anti-tumor necrosis factor-alpha (anti-TNF-alpha) medications. The effect of anti-TNF-alpha therapy on periodontitis also was assessed. METHODS: Forty participants diagnosed with moderate/severe RA (under treatment for RA) and severe periodontitis were randomly assigned to receive initial non-surgical periodontal therapy with scaling/root planing and oral hygiene instructions (n = 20) or no periodontal therapy (n = 20). To control RA, all participants had been using disease-modifying anti-rheumatic drugs, and 20 had also been using anti-TNF-alpha before randomization. Probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival index (GI), plaque index (PI), RA disease activity score 28 (DAS28), and erythrocyte sedimentation rate (ESR) were measured at baseline and 6 weeks later. Linear mixed models were used to identify significant differences between subjects who received periodontal treatment and those who did not. RESULTS: Patients receiving periodontal treatment showed a significant decrease in the mean DAS28, ESR (P <0.001), and serum TNF-alpha (P <0.05). There was no statistically significant decrease in these parameters in patients not receiving periodontal treatment. Anti-TNF-alpha therapy resulted in a significant improvement in CAL, PD, BOP, and GI. CONCLUSIONS: Non-surgical periodontal therapy had a beneficial effect on the signs and symptoms of RA, regardless of the medications used to treat this condition. Anti-TNF-alpha therapy without periodontal treatment had no significant effect on the periodontal condition.

A YAC mouse model for Huntington's disease with full-length mutant huntingtin, cytoplasmic toxicity, and selective striatal neurodegeneration.

We have produced yeast artificial chromosome (YAC) transgenic mice expressing normal (YAC18) and mutant (YAC46 and YAC72) huntingtin (htt) in a developmental and tissue-specific manner identical to that observed in Huntington's disease (HD). YAC46 and YAC72 mice show early electrophysiological abnormalities, indicating cytoplasmic dysfunction prior to observed nuclear inclusions or neurodegeneration. By 12 months of age, YAC72 mice have a selective degeneration of medium spiny neurons in the lateral striatum associated with the translocation of N-terminal htt fragments to the nucleus. Neurodegeneration can be present in the absence of macro- or microaggregates, clearly showing that aggregates are not essential to initiation of neuronal death. These mice demonstrate that initial neuronal cytoplasmic toxicity is followed by cleavage of htt, nuclear translocation of htt N-terminal fragments, and selective neurodegeneration.

Defects of DNA mismatch repair in human prostate cancer.

Loss of mismatch repair (MMR) function leads to the accumulation of errors that normally occur during DNA replication, resulting in genetic instability. Germ-line mutations of MMR genes in the patients with hereditary nonpolyposis colorectal cancer lead to inactivation of MMR protein functions, and the defects of MMR are well correlated to the high rate of microsatellite instability in their tumors. Previous studies (T. Uchida, et al. Oncogene, 10: 1019-1022, 1995; S. Egawa, et al. Cancer RES:, 55: 2418-2421, 1995; J. M. Cunningham, et al. Cancer RES:, 56: 4475-4482, 1996; X. Gao, et al. Oncogene, 9: 2999-3003, 1994; H. Rohrbach, et al. Prostate, 40: 20-27, 1999) have shown that genetic instability (chromosomal and microsatellite instability) is detectable in human prostate cancer. To elucidate the role of MMR genes in the tumorigenesis of prostate cancer, we evaluated the expression of these genes in human cancer cell lines and in tumor specimens. Using Western blot analysis, we detected loss among MSH2, MLH1, PMS2, and PMS1 proteins in DU145, LNCaP, p69SV40T, M2182, and M12 cells. In addition, genomic instability in the prostate cell lines including DU145, PC3, LNCaP, p67SV40T, M2182, and M12 was detected by a microsatellite mutation assay. Significantly, immunohistochemical analysis of prostatic tissue revealed the reduction or absence of MMR protein expression in the epithelium of prostate tumor foci compared with normal adjacent prostate tissue. In contrast to hereditary nonpolyposis colorectal cancer, characterized by defects predominantly in MLH1 and MSH2, the samples we examined showed more tumor foci with loss of PMS1 and PMS2. PMS1, which is only expressed in the basal cells in normal glands, is conspicuously absent in most prostate cancer. From these results, we conclude that there are defects of MMR genes in human prostate cancer.

A diabetic rabbit model for pig islet xenotransplantation.

An alloxan-diabetic rabbit model was established for the testing of the function of discordant xenogeneic pig islets isolated and purified from adult pig pancreata. The functional state of the pig islet transplants and immunological state of the rabbit recipients were assessed. Intraportal transplantation of 0.47 +/- 0.01 ml of pig islets with estimated 57418 +/- 5020 in number containing an estimated insulin content of 33.93 +/- 2.97 units (n = 7; mean +/- SEM) resulted in the normalization of blood glucose with a corresponding rise in insulin levels in the diabetic rabbit recipients for 2 days. An intravenous glucose tolerance test performed in 4 recipients during the normoglycemic period resulted in an improved K rate (2.5 +/- 0.4) over the diabetic controls, but this was significantly lower than the normal control animals (K rate = 4.5 +/- 0.4; n = 8). In vitro studies demonstrated that the preformed antibodies detected in the rabbit recipients were cytotoxic to the pig islet cells and lymphocytes. Heat treatment at 56 degrees C and mercaptoethanol treatment markedly reduced the cytotoxic activities of the sera. These findings implicated involvement of complement and IgM class antibodies in the killing of the pig islet cells. Furthermore, pig islet transplants at the kidney capsule site were coated with IgM class antibodies. This study has demonstrated that pig islets can be successfully isolated and purified in sufficient numbers for xenotransplantation studies in alloxan-diabetic rabbit. The porcine islet-to-alloxan diabetic rabbit combination can serve as a highly stringent and useful discordant model for assessing the effectiveness of various immunomodulation and immunosuppressive regimens. The finding of an optimal approach to immunorejection would potentially be applicable to actual clinical islet xenotransplantation in diabetic patients.

Transurethral resection of prostate via perineal urethrostomy: follow-up report.

A controlled, prospective clinical study was undertaken to determine the incidence and cause of urethral strictures after transurethral resection. Patients were assigned to one of three groups. Group A consisted of patients in whom it was considered preferable to perform prostatic resection through perineal urethrostomy; therefore, these were excluded from randomization. All other patients were randomized using a sealed envelope method into Group B who underwent resection via perineal urethrostomy and Group C who underwent resection via the entire urethra. Strictures occurred in 16.4 per cent of 85 patients in Group C and in 2.27 per cent of 88 patients in Group B; a statistically significant difference (p less than 0.01). It was concluded that strictures result from the trauma of the urethroscope via the entire urethra and not from the use of indwelling catheters. Perineal urethrostomy is the preferred route for prostatic resection and is mandatory whenever there is any question about the acceptability of the urethra to the resectoscope.

New continent ileocolonic urinary reservoir: Charleston pouch with minimally altered in situ appendix stoma.

A new continent urinary reservoir that utilizes minimally altered in situ appendix stoma is described. The reservoir was constructed from segments of terminal ileum and ascending colon which were detubularized and reorientated to provide maximum reduction in filling pressures. The in situ appendix was utilized to provide a continent catheterizable stoma. Appendicular leak pressures were measured intraoperatively to determine the need, if any, for augmentation. Minimal reinforcement of the appendiculo-colonic junction with two or three sutures was performed in most patients. Preliminary experience with 16 patients who had the Charleston pouch with an appendicular stoma as described herein is reviewed.

Accessory urethra with juxtaposed meatus.

A case report is presented of a juxtaposed urethral meatus and accessory urethra. The need for careful examination of the urethral meatus is emphasized.

Smooth muscle physiology and effect of bladder and urethra muscle length/tension on response to stimulation. Part I. Review.

With particular reference to the lower urinary tract, a review of basic anatomy and physiology of smooth muscle is presented. The relationship as altered by electrica and pharmacologic stimulation is discussed.

Effect of detrusor muscle length and tension on its response to pharmacologic and electrical stimulation. Part II. In vitro study.

The effect of varying lengths and tension of guinea pig detrusor strips on their response to pharmacologic and electrical stimulation was investigated. Our findings demonstrated that changes in muscle tension and length did alter the magnitude of the response to each agent tested.

Hereditary nephritis associated with vesicoureteral reflux and vaginal duplication.

The concomitant occurrence of vesicoureteral reflux and hereditary nephritis has not been previously reported. A case of a patient with hereditary nephritis, vesicoureteral reflux, and vaginal duplication is presented and the related literature reviewed. It is suggested that familial reflux may occur significantly in families with hereditary nephritis.

One-stage correction of chordee and 180-degree penile torsion.

The surgical management of a patient with 180-degree penile torsion, balanitic hypospadias, and chordee is presented. Complete resolution of the torsion was effected by completely reflecting the penile skin. Correction of the penile curvature was accomplished simultaneously by freeing the corpora spongiosa from the corpora cavernosa.

Concept of pharmacodynamics of urinary storage and micturition.

The exact neuropharmacologic sequences governing continence and micturition are not yet known. Based on current investigations and those previously conducted, a concept of the anatomic, physiologic, and neuropharmacologic factors governing continence and micturition is presented.

In vitro study of phenothiazine effects on urinary bladder.

Clinical observations suggest that long-term phenothiazine therapy can cause urinary retention and stress incontinence. The phenothiazines, chlorpromazine and perchlorperazine, depress bladder smooth muscle activity in vitro by depressing bladder smooth muscle activity directly and by a peripheral cholinergic blocking action.

Idiopathic segmental ureteritis.

A new case of nonspecific segmental ureteritis is added to the 18 cases previously reported. This case presented similar diagnostic problems to the previously reported cases. Its unique features are the multiplicity of the lesions and their insidious nonsimultaneous development over a number of years.

Leak point pressure use for intraoperative adjustment of the continence mechanism in patients undergoing continent cutaneous urinary diversion.

OBJECTIVES: Failure of the continence mechanism is the most common cause of unsatisfactory results and the need for revision in patients with continent cutaneous urinary diversion. We believed that incontinence in these patients could be eliminated or minimized by using the concept of leak point pressure intraoperatively to make appropriate adjustments and thus ensure adequate continence postoperatively. METHODS: The appropriate ileocolonic bowel segment for continent urinary diversion was isolated. Whenever the appendix was available, the unaltered or minimally altered appendicocolic junction was used for continence. In the absence of an appendix, the tapered distal ileum and reinforced ileocecal valve were used. Intraoperative leak point pressure (pressure at which leakage occurs) was measured before detubularization using a simple standing column manometer and arterial line tubing. Whenever leakage occurred at pressure less than 75 to 80 cm H2O, adjustment of the continence mechanism was performed and leak point pressure measurement was repeated to ensure adequate continence. RESULTS: Seventy-seven patients had long-term follow-up (30 to 100 months). These included 41 in whom the native appendix was used and 36 in whom the terminal ileum and ileocecal valves were used. Adjustment of the continence mechanism was required in 32 of the 41 patients in whom the native appendicocolic junction was used and in all 36 patients in whom the tapered ileum and ileocecal valve were used. After adjustment, all patients attained leak pressures over 80 cm H2O. At the last follow-up visit, all 77 patients were continent on intermittent catheterization every 3.5 to 6 hours. None has required revision of the continence mechanism. CONCLUSIONS: Intraoperative measurement of leak point pressure is valuable in predicting the need for adjusting the continence mechanism and eliminating or substantially minimizing the need for subsequent revision.

Extent of bladder and ureteric involvement and urologic management in patients with enterovesical fistulas.

A retrospective review of hospital charts from 1978-1989 identified 21 patients with acquired enterovesical fistulas. Nine patients with fistulas secondary to benign inflammatory processes required extensive bladder resection; 2 of these had ureteric involvement. Of the 9 patients requiring extensive bladder resection, necrotic and severely inflamed bladder was excised and the bladder was closed in a multilayered fashion with absorbable sutures. An omental flap was used when possible. Postoperative bladder drainage was maintained for seven to fourteen days. Ureteral involvement was managed by stenting in 1 case and ureteroureterostomy in another. No postoperative bladder leaks or recurrent fistulas were reported. Extensive inflammatory involvement of the bladder wall may necessitate a large vesical resection. Excision of diseased bladder tissue, multilayered closure, and the use of omental interposition may help reduce postoperative complications and the risk of recurrence. Associated ureteral involvement may be present in these patients and requires urologic management.

Uropharmacology: IV. Parasympathomimetic drugs.

Parasympathomimetic drugs include (1) acetylcholine and several synthetic choline esters and related derivatives, and (2) naturally occurring cholinomimetic alkaloids and certain related synthetic compounds. Pharmacology of acetylcholine, the prototype parasympathomimetic, is presented, as well as an introduction to other parasympathomimetic drugs and choline esters.

Uropharmacology: VIII. Sympathomimetic agents.

Sympathomimetic drugs stimulate the receptors of the sympathetic nervous system. Although the bladder possesses sympathetic receptors, sympathomimetic drugs, in general, have little effect on bladder function. Their most useful clinical applications on the urinary tract are to increase or decrease bladder resistance.

Management of neoplasms in vesical diverticula.

Two cases of neoplasms occurring in vesical diverticula are presented, and the pertinent literature is reviewed. It is suggested that a patient with a neoplasm in a vesical diverticulum be staged by surgical exploration and be accorded the same aggressive management as any patient with an infiltrating vesical neoplasm.