G. H. Jacobi

The Mainz Pouch (Mixed Augmentation Ileum and Cecum) for Bladder Augmentation and Continent Diversion

AbstractThe surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: 1) creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, 2) antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and 3) in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis.Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the rema...

Radical cystectomy : Often too late?

From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.

100 Cases of Mainz Pouch: Continuing Experience and Evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.

The mainz-pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent diversion

SummaryThe ideal urinary reservoir constructed from bowel material should be a low-pressure system with a high capacity, capable of preventing upper tract deterioration resulting from ureteral obstruction or reflux. It should achieve reliable control of continence and assure easy emptying of the reservoir. In the Mainz-pouch, the combination of cecum and ileum, the latter of which is able to absorb pressure waves created by the cecum, produces a low-pressure system with a high capacity immediately postoperatively. By incorporating large bowel in our pouch, ureteral implantation can be done using a simple and reliable standard antireflux technique with a submucosal tunnel. The Mainz-pouch has been done since 1983 in 26 patients. Of these 11 were for bladder augmentation after subtotal cystectomy and 15 for continent urinary diversion. All of the patients with bladder augmentation are completely dry day and night; 2 patients with myelomeningocele are on intermittent catheterization for bladder evacuation. The remainder void spontaneously without significant residual urine. Of 15 patients with Mainz-pouch urinary diversion, 4 had an alloplastic stomal prosthesis implanted for control of continence and 11 have isoperistaltic ileo-ileal invagination, where by the invagination valve can easily be fixed to the intussuscepting ileum by sutures or staples. Of the 4 alloplastic stomal prostheses, 2 have been removed because of infection. In 1 of these patients, an ileo-ileal invagination was performed in the same operation to achieve continent closure. All patients with the invagination valve, as well as the 2 patients with an alloplastic stomal prosthesis, are completely continent, but in 3 cases, revision of the ileo-ileal invagination became necessary due to prolapse of the valve.

Silicone-Silver Penile Prosthesis: Description, Operative Approach and Results

A silicone penile prosthesis in which silver wires are embedded to allow for voluntary bending of the penis for urination and resting position and for straightening for intercourse is described. The implantation is done via a hemicircular incision on the dorsum of the penis in the sulcus coronarius. Bucks fascia is identified and opened, and the corpora are dilated up to 30F. After the exact length is determined with a special sizer the prosthesis is slipped into each corpus cavernosum. The advantage of this approach is the optimal insertion of the prosthesis distal to the sulcus coronarius, thereby preventing kinking of the glans during intercourse. Our experiences with the implantation in 17 patients followed for 1 to 14 months showed successful results in 15.

Studies on the intravesical action of topically administered G3H-doxorubicin hydrochloride in men: plasma uptake and tumor penetration.

AbstractDoxorubicin hydrochloride has been used for the treatment and prevention of recurrences of transitional cell carcinoma. Ideal indications for the drug and side effects have not been determined. In this regard the penetration of the drug into the bladder wall and the urothelium as a urinary blood barrier is of interest. Using a tritium label we have investigated tumor penetration and transmucosal plasma uptake of doxorubicin hydrochloride after intravesical application in 7 patients with stage A bladder tumors. Of the 7 patients 5 were free of tumor following transurethral resection and 2 had recurrent disease. The patients free of tumor received 40mg. doxorubicin hydrochloride per 30ml. normal saline with 1.2mg. G3H-doxorubicin hydrochloride (27.8mCi./mMol.) intravesically for 2hours. Blood was drawn for up to 120 minutes and plasma was assayed for radioactivity. The patients with recurrent papillary tumor received 2.3mg. labeled doxorubicin hydrochloride along with 40mg. cold substance and underw...

Extracorporeal shock wave lithotripsy (ESWL): alternatives and adjuvant procedures

SummaryWithin a short time, extensive statistics on ESWL have documented its efficiency in the treatment of most renal and ureteral stones. Approximately 20% of all stone patients, however, require additional or other forms of therapy, such as URS, PNL, or surgery. Up to now, the differential indications for these procedures have not been completely established. A crucial factor for successful application of ESWL is stone volume and localization. Large stones with a central stone mass may be successfully treated by combining ESWL and PNL, while surgery is still preferred in those with a peripheral stone mass.

Gonadotropin-releasing hormone analogues for palliation of carcinoma of the prostate

SummarySince the introduction of contrasexual treatment as the basic concept of palliation of prostatic carcinoma in the 1940s, orchiectomy, estrogens, and, in recent years, antiandrogens have become generally accepted treatment forms. Three facts: 1) estrogen treatment being at best palliative and at worst dangerous; 2) surgical castration having psychological impacts, at least in the younger age group; and 3) both being probably ineffective from the beginning, have led us to investigate an alternative of minimal toxicity and possible reversibility in the initial treatment of advanced prostatic carcinoma. 12 patients with far advanced carcinoma of the prostate were treated with the gonadotropin releasing hormone analogue [D-Ser(But)6]-LH-RH(1-9)-nonapeptide ethylamide (Buserelin, Hoe 766), which caused down-regulation of pituitary luteinizing hormone (LH) receptors and suppressed testosterone to castrate levels within four weeks. The production rate of testosterone (PR-T) was lowered to values comparable to those after bilateral orchiectomy within two weeks. Subjectively, patients responded favorably with a relief of metastatic bone pain in all cases and an improvement of the Karnofsky Performance Index to an average score of 75 in those patients who had had an initially low index averaging 45. Objective responses included reduction of local tumor mass with resolution of bilateral ureteral obstruction, regression of pulmonary and bone metastases, and decrease of initially elevated serum acid phosphatase concentration. On the basis of these preliminary data, it should be expected that treatment of far advanced prostatic adenocarcinoma with gonadotropin-releasing hormone analogues is a safe, nontoxic and effective form of palliation.

Urachal Signet-ring Cell Carcinoma, A Rare Variant of Vesical Adenocarcinoma: Incidence And Pathologicalcriteria

Of 715 cases of vesical tumors reviewed 18 adenocarcinomas were selected for further study, 5 of which fulfilled all criteria of urachal origin. Herein is reported 1 rare case of such a carcinoma of the signet-ring cell type and the morphological criteria of this variant are discussed briefly. After undergoing radical cystectomy and ureterosigmoidostomy the patient has been free of recurrent tumor or metastasis for 6 years.

Bromocriptine and prostatic carcinoma: plasma kinetics, production and tissue uptake of 3H-testosterone in vivo.

The influence of the anti-prolactin bromocriptine on plasma kinetics, production rate and tissue uptake of testosterone was investigated in 15 patients with newly diagnosed stages C and D prostatic carcinoma. Bromocriptine was given for 5 days in a daily dose of 15 mg. orally. The studies were performed with the single injection technique using the 2-compartment model. Plasma testosterone, serum prolactin, and luteinizing and follicle-stimulating hormones were determined initially. Blood samples were drawn up to 5 hours after the injection of 3H-testosterone. For tissue studies a transrectal needle biopsy was done 3 hours post-injection. Bromocriptine suppressed prolactin and the endogenous testosterone level. Furthermore, it favored the elimination of 3H-testosterone, lowered the production rate of testosterone and hampered the in vivo uptake of the 3H-label into prostatic carcinoma tissue. Finally, the grading of the tumor lesions affected only the pre-bromocriptine uptake of radioactive androgens and not the uptake in response to bromocriptine. The potential clinical impliications of these observations are discussed.