E. Alcini

Vitamin B12 and folic acid plasma levels after ileocecal and ileal neobladder reconstruction

OBJECTIVES To compare the plasma levels of vitamin B12 and folic acid following resection of ileocecal or ileal segments used for orthotopic bladder substitution. METHODS Hemoglobin, hematocrit, and plasma levels of vitamin B12 and folic acid were measured in 34 patients with ileocecourethrostomy (ICUS) and in 16 patients with ileal reservoir (IR), with a mean follow-up of 59.8 +/- 41.9 months. The results were compared with regard to both the type of operation and the length of time since surgery. RESULTS The level of folic acid was normal in all patients. The mean level of vitamin B12 in the ICUS group was 413.67 +/- 160.45 ng/mL compared to 257.63 +/- 121.36 for the IR group. This difference was statistically significant. In the IR group, 18.75% of the patients had a level of vitamin B12 below normal. CONCLUSIONS There is a tendency for vitamin B12 levels to fall in patients in whom the ileum is used. Resection of the ileocecal segment including the junction does not alter the level of vitamin B12.

Acid-base and electrolyte balance in urinary intestinal orthotopic reservoir: ileocecal neobladder compared with ileal neobladder

OBJECTIVES To compare acid-base and electrolyte balance in ileocecal and ileal neobladders. METHODS Acid-base and electrolyte balance were studied in 45 patients with an ileocecourethrostomy and 18 patients with an ileal reservoir. The mean follow-up was 51 months. Results were compared with regard to both the type of operation and the time since surgery. RESULTS No significant differences were found with regard to either the type of operation or the length of follow-up. A preserved renal function is important in maintaining a healthy status. CONCLUSIONS The use of 35 to 40 cm of ileum or 10 cm of cecum with the ileocecal junction seems to be safe even after a long follow-up. The length rather than the kind of bowel used for bladder replacement appears to be important in safeguarding hydroelectrolyte and acid-base homeostasis. This is particularly true in the presence of preserved renal function.

Growth-Inhibitory Effect of Quercetin and Presence of Type II Estrogen Binding Sites in Primary Human Transitional Cell Carcinomas

Eight cases of transitional cell carcinoma (TCC) of the bladder were investigated for the presence of estrogen receptors (ER) and Type II estrogen binding sites (Type II EBS). All these tumors specifically expressed type II EBS, while only 3 of 8 cases contained low amounts of ER. All the cases assayed for the presence of both nuclear and cytoplasmic type II EBS revealed the presence of these binding sites in the two compartments. Both cytoplasmic and nuclear receptors were similar to type II EBS described in other tissues relative to their binding specificity for estrogens and quercetin and their sensitivity to reducing agents. Quercetin, 10 microM., was effective in inhibiting in vitro bromodeoxyuridine (BrdUdR) incorporation by TCC cells. Rutin, which bound little if any to type II EBS, did not show any inhibitory effect on in vitro BrdUdR incorporation by tumor cells, suggesting a type II EBS mediated effect of flavonoids. Although the mechanism of the antiproliferative activity of quercetin remains to be fully clarified, the possible therapeutic potential of quercetin and related flavonoids should be considered.

PATIENT SELECTION CRITERIA IN THE SURGICAL TREATMENT OF VENO-OCCLUSIVE DYSFUNCTION

PURPOSE We evaluated short and long-term results of simple and complex venous surgery in patients with veno-occlusive dysfunction unresponsive to maximum recommended doses of intracavernous alprostadil, who were selected with newly developed diagnostic indicators. MATERIALS AND METHODS A total of 23 impotent men with a mean age of 41 years (range 20 to 50) underwent complex penile venous surgery. Only patients fulfilling at least 3 criteria were included in study. The criteria were mild cavernous leak assessed by cavernosometry (grades 1 and 2), more than 30% cavernous smooth muscle tissue (histomorphometric analysis), normal analogical corpus cavernosum electromyography recordings according to international standards, cavernosal oxygen tension greater than 65 mm. Hg at erection and age younger than 50 years. RESULTS Of 23 patients 17 (74%) had normal erections within a year after surgery, and 5 of them (29%) complained of recurrent erectile dysfunction. At long-term followup 6 of 12 patients had spontaneous erections. CONCLUSIONS Careful selection with advanced diagnostic techniques should be mandatory before performing venous surgery in patients with high degree veno-occlusive dysfunction as the only alternatives are major therapeutical solutions.

Results of 4 years of experience with bladder replacement using an ileocecal segment with multiple transverse teniamyotomies

Since 1987, 30 patients with bladder cancer underwent cystoprostatectomy with bladder replacement via ileocecourethrostomy. Multiple transverse teniamyotomies were made in the cecum to assure a large capacity reservoir with low pressures. The particular anatomy and physiology of the cecum, short length of the intestinal segment needed and teniamyotomies are the 3 factors that have allowed for good functional and metabolic results. All patients achieved daytime continence. After 3 years of followup 67% of the patients were continent at night if they voided every 3 or 4 hours and 22% if they voided every 2 or 3 hours, while 11% experienced enuresis. Urodynamic data after 1 year showed a mean capacity of 396 ml. for the new bladder, a mean full filling pressure of 28 cm. water and a mean maximum pressure of 55 cm. water. Post-micturition residual urine volume was consistently less than 55 ml. These results indicate that the ileocecal segment can be enlarged with myotomies through the tenia to produce an adequate capacity and a low pressure bladder replacement without the need for formal detubularization.

Acute idiopathic scrotal oedema: Rare disorder or difficult diagnosis?

This study reports our experience in 6 cases of acute idiopathic scrotal oedema. Although children were the primary targets, this pathologic condition was also encountered in adults.Specific diagnosis of acute idiopathic scrotal oedema, opposed to other causes of scrotal swelling, is based on history, an objective examination, velocimetric Doppler exam and echography. Correct diagnosis is important in order to avoid unnecessary surgery.We are inclined to consider acute idiopathic scrotal oedema as an allergic disorder and recommend a follow-up within two days.

Adenocarcinoma of the urachus: radical or conservative surgery? A report of a case and a review of the literature

AIMS To identify the most appropriate surgical strategy for carcinoma of the urachus. METHODS Analysis of a case of adenocarcinoma of the urachus and an examination of the current literature were carried out. CONCLUSIONS Partial cystectomy is considered the most appropriate surgical strategy but the need for close follow-up is underlined.

Corpus cavernosum electromyography (CC-EMG): A new technique in the diagnostic work-up of impotence

We have studied cavernous electrical activity in 42 subjects, healthy volunteer controls and groups of impotent, patients using a nonspecific electromyographic device (PICO-MENFIS) and a specific one, the SPACE-recorder 7500 designed to achieve electric recordings from the corpora cavernosa. In all of the patients, we detected under basal conditions a mean amplitude of 583±323 μV, a mean duration of 4.9±7 s,a mean polyphasicity of 3.5±1.4. It should be emphasized that a significant reduction of potential amplitudes was recorded after pharmacological stimulation in both the controls and the impotent patients. The healthy controls showed amplitudes significantly higher than the impotent patients after radical cystectomy (715±141 μV versus 381±227 μV, p<0.01).The patients after a “nerve-sparing” radical cystectomy with a mean amplitude similar to the controls (500–700 μV) reacted well to the intracavernous drugs in a high percentage of cases.In our experience, CC-EMG seems to be a reliable method which can pinpoint directly lesions to the cavernous smooth muscle and penile autonomic nerves. It has also been able to assess the effects of stress, anxiety and pain on the erectile mechanisms.

Refluxes in orthotopic neobladders: Canthe ileocecal sphincter be considered an adequate antireflux mechanism?

OBJECTIVES To evaluate the usefulness of the ileocecal sphincter in preventing ureteral refluxes in ileocecal orthotopic neobladder, thus avoiding the use of antireflux technique for ureteroileal anastomosis. METHODS From 1980 to 1992, 95 patients underwent orthotopic bladder substitution. In 30 our detubularized ileal reservoir was used and in 65 first only an integral ileocecal segment was used and subsequently multiple transverse teniamyotomies on the cecal portion to increase the capacity and reduce the pressure. The upper urinary tract was indirectly protected in the ileal reservoir technique by leaving an integral 8 to 10 cm long afferent segment folded behind the reservoir and in the ileocecal technique by the ileocecal sphincter, thus keeping the anastomosis between ureters and ileum simple and direct. RESULTS The mean follow-up of the 65 patients with ileocecourethrostomy is 37 +/- 33 months (range, 2 to 141 months); in 13.8% of the patients (9/65) monolateral refluxes appeared, but without any evident clinical consequences. The appearance of monolateral stenosis on the ureterointestinal anastomosis requiring treatment occurred in 4 patients (6%): 3 underwent an endoscopic treatment and 1 a surgical one. Modifications of renal function with respect to the preoperative status were not verified in any of the patients. CONCLUSIONS The ileocecal sphincter is an effective antireflux mechanism for an orthotopic neobladder in which multiple transverse teniamyotomies (5 to 7) increase the capacity of the neobladder itself, reduce its internal pressure, and confer a nearly spherical configuration. Moreover, a correct anastomosis between the cecum and membranous urethra decisively reduces the resistance to emptying of the neobladder, thus avoiding too strong pressures against the ileocecal sphincter. The integrity of the circular muscular layer maintains a healthy tonic wall: this fact, combined with the low peripheral resistances, ensures good emptying and a stable capacity. The procedure is easy to perform and not time-consuming; these considerations lead us to consider the ileocecal unit an excellent structure for bladder substitution.

XYLOSE ABSORPTION AND METABOLIC STATUS IN URINARY INTESTINAL ORTHOTOPIC RESERVOIR: ILEOCECAL COMPARED WITH ILEAL NEOBLADDER

PURPOSE We compare the absorption of D-xylose and vitamin B12, and the metabolic status in ileocecal and ileal orthotopic neobladders. MATERIALS AND METHODS D-xylose plasma levels after an oral load, body composition, plasma vitamin B12, acid base and electrolyte balance were studied in 33 patients with an ileocecal reservoir and 13 patients with an ileal reservoir. Mean followup was 55 months. Results of both types of operation and a healthy control group were compared. RESULTS Plasmic levels of D-xylose and vitamin B12 were significantly lower in the ileal reservoir than in ileocecal reservoir group and normal controls. CONCLUSIONS Despite an acceptable body composition, intestinal malabsorption could be present in patients with an ileal reservoir but the ileocecal tract appears to be safe.