Appendicocecal Loop Urinary Diversion in a Transplant Kidney: Case Report, Literature Review.

Urinary diversion in renal transplant patients can take a variety of forms - bladder augmentation, continent cutaneous pouch, or intestinal conduits, to name a few. Herein, we present a unique case of an appendicocecal urinary diversion in a patient with history of end stage renal disease, pelvic radiation, and complex surgical history who underwent deceased-donor renal transplantation. During the renal transplant, the transplant ureterovesical anastomosis could not be performed due to inherent anatomical hindrances. A temporary modified cutaneous ureterostomy using a single-J stent was therefore used for drainage of the transplant kidney. Given that the cutaneous ureterostomy was not a durable, long-term option, we sought to develop a creative surgical solution. This report presents a unique case of urinary diversion post renal transplant and reviews the literature of renal transplantation in patients with anatomical abnormalities.

A regulatory BMI1/let-7i/ERK3 pathway controls the motility of head and neck cancer cells.

Extracellular signal-regulated kinase 3 (ERK3) is an atypical mitogen-activated protein kinase (MAPK), whose biological activity is tightly regulated by its cellular abundance. Recent studies have revealed that ERK3 is upregulated in multiple cancers and promotes cancer cell migration/invasion and drug resistance. Little is known, however, about how ERK3 expression level is upregulated in cancers. Here, we have identified the oncogenic polycomb group protein BMI1 as a positive regulator of ERK3 level in head and neck cancer cells. Mechanistically, BMI1 upregulates ERK3 expression by suppressing the tumor suppressive microRNA (miRNA) let-7i, which directly targets ERK3 mRNA. ERK3 then acts as an important downstream mediator of BMI1 in promoting cancer cell migration. Importantly, ERK3 protein level is positively correlated with BMI1 level in head and neck tumor specimens of human patients. Taken together, our study revealed a molecular pathway consisting of BMI1, miRNA let-7i, and ERK3, which controls the migration of head and neck cancer cells, and suggests that ERK3 kinase is a potential new therapeutic target in head and neck cancers, particularly those with BMI1 overexpression.

Cystoisospora belli Infection of the Gallbladder in Immunocompetent Patients: A Clinicopathologic Review of 18 Cases.

Cystoisospora belli, previously known as Isospora belli, is an obligate intracellular coccidian parasite that is most often associated with gastrointestinal disease in immunocompromised patients. In this study, we detail the clinicopathologic features of 18 cases of Cystoisospora infection affecting the gallbladder in immunocompetent individuals and compare them with a control group. Each case was reviewed for cholecystitis (none, acute, chronic), epithelial disarray, presence of intraepithelial lymphocytes (none, rare [≤5 per 20 epithelial cells], present [>5 per 20 epithelial cells]), architectural distortion, intramucosal eosinophilia, and mural thickening/serositis. The mean age of patients with Cystoisospora infection was 33 years and the male to female ratio 1:4.3. Cholecystectomy was performed for biliary dyskinesia (n=7), abdominal pain (n=7), suspected cholelithiasis (n=5), and cholecystitis (n=3). In 2 cases, Cystoisospora was found in donor gallbladders resected at the time of liver transplantation. Each case was characterized by eosinophilic, oval or banana-shaped intraepithelial parasites within perinuclear parasitophorous vacuoles. Most cases showed epithelial disarray and minimal intraepithelial lymphocytosis. Of the 11 cases with an average follow-up of 15 months, none had evidence of disease related to Cystoisospora infection within the biliary tract or elsewhere in the gastrointestinal tract. We present the largest series of gallbladder cystoisosporiasis in immunocompetent patients to date. Cystoisospora infection is underrecognized in the gallbladders of immunocompetent patients, in part due to the subtle findings in routine cholecystectomy specimens. On the basis of the clinical follow-up, gallbladder cystoisosporiasis in immunocompetent individuals appears to be a self-limited infection.

Acid-fast Smear and Histopathology Results Provide Guidance for the Appropriate Use of Broad-Range Polymerase Chain Reaction and Sequencing for Mycobacteria.

CONTEXT: New molecular diagnostic tests are attractive because of the potential they hold for improving diagnostics in microbiology. The value of these tests, which is often assumed, should be investigated to determine the best use of these potentially powerful tools. OBJECTIVE: To investigate the usefulness of broad-range polymerase chain reaction (PCR), followed by sequencing, in mycobacterial infections. DESIGN: We reviewed the test performance of acid-fast bacilli (AFB) PCR and traditional diagnostic methods (histopathology, AFB smear, and culture). We assessed the diagnostic effect and cost of the unrestricted ordering of broad-range PCR for the detection and identification of mycobacteria in clinical specimens. RESULTS: The AFB PCR was less sensitive than culture and histopathology and was less specific than culture, AFB smear, and histopathology. During 18 months, $93 063 was spent on 183 patient specimens for broad-range PCR and DNA sequencing for mycobacteria to confirm one culture-proven Mycobacterium tuberculosis infection that was also known to be positive by AFB smear and histopathology. In this cohort, there was a false-negative AFB PCR for M tuberculosis and a false-positive AFB PCR for Mycobacterium lentiflavum . CONCLUSION: Testing of AFB smear-negative specimens from patients without an inflammatory response supportive of a mycobacterial infection is costly and has not been proven to improve patient care. Traditional diagnostics (histopathology, AFB smear, and culture) should remain the primary methods for the detection of mycobacteria in clinical specimens.

The oral mucosa graft: a systematic review.

PURPOSE: We provide the reader with a critical, nonbiased, systematic review of current and precedent literature regarding the use of oral mucosa in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. MATERIALS AND METHODS: We reviewed pertinent English literature from January 1966 through August 1, 2006 via the databases MEDLINE/PubMed, the Cochrane Library, and EMBASE Drugs and Pharmacology regarding the use of oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias. Bibliographies of pertinent articles were explored for additional important literature. RESULTS: Data were stratified among studies that only used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with stricture, and those that used oral mucosa graft urethroplasty in the reconstruction of urethral defects associated with hypospadias/epispadias. Recipient site success in the reconstruction of defects associated with stricture was significantly associated with the location of graft placement (ventral vs dorsal, p <0.001) when an onlay graft was used. Hypospadias/epispadias recipient site success was significantly associated with the type of graft used (tube vs onlay, p <0.001), and by the site of oral mucosa harvest (labial vs buccal, p <0.001). Other perioperative and patient oriented variables were not significantly associated with success at the recipient site. CONCLUSIONS: The oral mucosa is a viable source of donor tissue displaying many characteristics of the ideal urethral graft. There are numerous variations of the oral mucosa graft urethroplasty technique. Herein comparisons are made.

Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications.

PURPOSE: Despite an aging population, the results of urethroplasty in elderly patients have not been extensively reported. We performed a multi-institutional review of urethroplasty results in 70 elderly males to determine outcomes. MATERIALS AND METHODS: We reviewed all urethroplasties performed on males older than 64 years with at least 6 months of followup at 4 medical centers. Stricture type varied and included anastomotic urethroplasty (44%), penile fasciocutaneous onlay flap (31%), Johanson urethroplasty (stage 1, 6%, stages 1 and 2, 4%), buccal mucosa grafts (7%), foreskin grafts (6%) and meatoplasty (1%). RESULTS: Stricture recurred in 11 (16%) patients, but was managed with a single direct visual internal urethrotomy or dilation in 5 of 11 patients, yielding a final success rate of 91%. Recurrent strictures were more common after fasciocutaneous flaps (7 of 22 cases, 32%) than end-to-end urethroplasty (2 of 31 cases, 6%, p <0.05). Compared to patients younger than 65 years there were more treatment failures, but this was not statistically significant. Perioperative complications were uncommon. Moderate bladder outlet obstructive symptoms developed in 3 patients due to benign prostatic hyperplasia. Notably 6 patients treated previously for post-radiation strictures did well without complications. CONCLUSIONS: Older men tolerate urethroplasty and these data indicate that therapy should not be withheld solely on the basis of age. The potential for impaired flap blood supply in this population is suggested but has not been proven. Benign prostatic hyperplasia must be considered in those patients who have decreased stream after stricture repair.