Darwich E. Bejany

Malignant Vesical Tumors Following Spinal Cord Injury

We present 11 male patients with spinal cord injury and neurogenic bladder disease in whom malignant vesical tumors developed. The incidence of these tumors in our spinal cord injury unit was 2.3 per cent. We investigated retrospectively the clinical, endoscopic and radiographic diagnoses, and analyzed the treatment. The most common presenting symptoms were recurrent urinary infections, hematuria and stone disease. Two patients presented with abdominal symptomatology (a large abdominopelvic mass and peritonitis). Endoscopic evaluation was nonspecific in 8 patients (72 per cent). Squamous cell carcinoma was present in 9 patients (81 per cent). One patient had pure transitional cell carcinoma, and 1 had mixed squamous and transitional cell cancer. Cytology was of no value in these patients. The presence of local invasion and bulky disease suggests that ultrasonography or computerized tomography of the abdomen and pelvis should be included during followup. Radical cystoprostatectomy with pelvic lymphadenectomy is the recommended therapy for localized disease. The presence of active or recurrent urethral disease in 55 per cent of the patients indicated that urethrectomy also should be performed.

Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir

A continent colonic urinary reservoir was created in 10 patients who had undergone anterior exenteration for invasive bladder carcinoma. A tapered distal ileal segment with a catheterizable abdominal stoma provided full continence in all 10 patients. Tapering of the terminal ileum was achieved with a gastrointestinal anastomosis stapler in 5 patients or with a bowel clamp in 5 others. Three purse-string sutures of 2-zero silk were placed on the tapered ileal segment to increase the intraluminal pressure. A nontunneled ureterocolonic anastomosis was performed in all 20 ureters. No obstruction or reflux was noted in 19 ureters (95 per cent). Hydronephrosis at the anastomotic site was noted in 1 ureter and was successfully dilated percutaneously.

Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary?

Objectives. To evaluate the use of interposition flaps in repairing vesicovaginal fistulas (VVFs) of benign and malignant etiologies. Interposition flaps are not routinely used in the repair of VVFs when the surrounding tissues appear healthy and well-vascularized, such as in a benign etiology.Methods. We retrospectively reviewed the charts of 37 women (mean age 49.1 years) at our institution who underwent transabdominal repair of their VVF by urologic surgeons between August 1978 and June 1999. The preoperative and postoperative medical records were reviewed.Results. Of the 37 VVFs repaired transabdominally, 29 had a benign etiology (25 related to gynecologic procedures) and 8 a malignant etiology (all related to gynecologic neoplasia). Of the 29 benign VVFs, an interposition flap was used in 10 repairs with all 10 successful (100%). The remaining 19 benign VVF repairs were performed without using a flap, with 12 successful (63%). Of the 8 malignant fistulas, an interposition flap was used in 2 repairs with both successful (100%). The remaining 6 malignant VVF repairs were performed without a flap, with 4 successful (67%).Conclusions. The results of our study indicate a higher success rate for transabdominal VVF repairs performed with an interposition flap (100% success rate at our institution). This observation holds true regardless of the appearance of healthy surrounding tissue or, more importantly, a benign or malignant etiology. We recommend interposition flaps in transabdominal repairs of VVFs, even in the cases of benign fistulas with well-preserved surrounding tissue.

Continent urinary diversion in gynecologic oncology

Pelvic exenteration is a salvage procedure used primarily for recurrent gynecologic carcinoma. Up to the present time, an ileal or colon conduit has been used for urinary diversion and the patient remains incontinent of urine. This is a preliminary report of nine patients with gynecologic carcinoma in whom a continent urinary diversion procedure was performed. A segment of distal ileum, the ascending colon, and part of the transverse colon are used to create the colonic reservoir. The segment of colon is opened along the tenia and folded onto itself. The walls of the ascending and transverse colon are anastomosed to detubularize this segment of bowel and eliminate the transient high pressure of the colon. Surgical staples are used for the anastomosis. The segment of ileum is tapered and three purse-string sutures (2-O silk) are placed at the level of the ileocecal valve to achieve continence. The short segment of ileum is then exteriorized as a stoma through which the patient catheterizes. Antirefluxing, non-tunneled ureterocolonic anastomoses are performed. The anterior wall of the reservoir is closed with absorbable staples. Postoperative urodynamic studies have shown maximum capacity of 750 ml and the area of continence to be at the ileocecal valve where the purse-string sutures are placed. All patients are continent and postoperative radiographs were negative for reflux. Follow-up was 6 to 12 months. The colonic reservoir is a capacious low-pressure system and warrants further clinical trials in patients with gynecologic cancer.

Augmentation Cystoplasty in the Management of Neurogenic Bladder Disease and Urinary Incontinence

Vesical augmentation procedures were performed on 15 patients for neurogenic bladder disease and urinary incontinence. Enterocystoplasty with ileum, cecum and sigmoid was used associated with different operations to prevent upper tract deterioration or urinary incontinence. The small bowel stored larger amounts of urine at a lower maximal detrusor pressure at capacity than the large bowel. All ureterointestinal and ureterovesical reimplantations were successful, including 5 ureteroileal with the Camey procedure. The 2 failures, characterized by persistent urinary incontinence, included a male patient who refused intermittent catheterization and a girl with persistent hypersecretion of mucus and recurrent urinary tract infections.

Ileocolic Neobladder in the Woman With Interstitial Cystitis and a Small Contracted Bladder

Bladder substitution with an ileocolic segment after total cystectomy was performed in 5 women with a severely contracted bladder secondary to interstitial cystitis. The urethra was divided at the bladder neck in 2 patients and distal to it in 3. The latter 3 patients empty the bladder to completion and void naturally, while the former 2 have a large post-void residual volume and require intermittent self-catheterization. Mean patient age was 50 years and mean followup was 52 months. All patients have complete diurnal and nocturnal continence, and are free of all symptoms related to interstitial cystitis. Total bladder replacement in women with interstitial cystitis and a contracted bladder significantly improved the quality of life and is an ideal alternative to other forms of urinary diversion.

Diluted epinephrine solution for the treatment of priapism

We report our experience with 18 consecutive cases of priapism treated with intracorporeal irrigations of dilute epinephrine solution. Of the 18 patients 16 were treated successfully. The 2 failures had priapism 36 hours and 5 days in duration, respectively.

Gangrene of the Penis after Implantation of Penile Prosthesis: Case Reports, Treatment Recommendations and Review of the Literature

We report 3 cases of gangrene of the penis seen at our institution after penile prosthesis implantation. All 3 patients had insulin-dependent diabetes mellitus. Amputation was required in 2 patients. Aggressive debridement in conjunction with hyperbaric oxygen prevented amputation in the third patient.

Complications of the Miami Pouch

The Miami pouch, a continent colonic urinary reservoir, was constructed in 75 patients after cystectomy for invasive bladder tumor (44), gynecological tumor (25), neurogenic bladder (4) and conversion of an ileal conduit (2). Continence was achieved by tapering the distal ileum over a 14F catheter and reinforcing the ileocecal valve with 3 circumferential silk sutures in a pursestring fashion. Ureterocolonic anastomosis was performed in a nontunneled fashion. There were 5 perioperative deaths. One or more early (perioperative) complications occurred in 19 patients (26%). Late complications (beyond 6 weeks) were found in 16 patients (23%). Total continence rate was 98.6% and the success rate of the ureterocolonic anastomosis was 90%. Followup was 7 to 69 months. We present a review of the technical aspects of the construction of the Miami pouch, and the early and late complications associated with this procedure.

Antireflux Ureteroileal Reimplantation: An Alternative for Urinary Diversion

Direct antireflux ureteroileal reimplantation with a short (2 to 2.5 cm.) intraintestinal ureteral segment was used in 14 patients with 26 ureters reimplanted into the ileum as part of a bladder augmentation procedure, substitution cystoplasty or continent supravesical diversion. Our incidence of reflux was 3.8 per cent (1 ureter), while ureteroileal obstruction occurred in 11.4 per cent (3 ureters). The over-all short-term technical success (maximum 18 months) with this operation was 84.8 per cent. These encouraging results make antireflux ureteroileal reimplantation an attractive alternative for its use in urinary tract reconstruction with ileal reservoirs.