Michael D. Melekos

Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women.

PURPOSE We evaluated and compared the efficacy of post-intercourse and daily oral ciprofloxacin prophylaxis against recurrent lower urinary tract infections in 135 sexually active premenopausal women. MATERIALS AND METHODS Post-intercourse (group 1, 70 patients) and daily (group 2, 65 patients) prophylactic regimens of 125 mg. ciprofloxacin were started following a curative, conventional treatment of the initial acute urinary tract infection. Prophylaxis was maintained for 12 months and during this period patients were followed clinically and bacteriologically with urine and introital samples. Patients were subsequently followed for an additional year after the end of preventive treatment. RESULTS While 3.67 urinary tract infections per patient in group 1 and 3.74 in group 2 occurred during an identical mean time of 12.2 months before start of the corresponding prophylactic regimen, only 0.043 infection per patient in group 1 and 0.031 in group 2 developed during prophylaxis (p < 0.0001). Before prophylaxis 86% of the vaginal vestibule cultures yielded gram-negative Enterobacteriaceae, equally distributed between both treatment arms, compared to 5.6% and 2.5% during postcoital and daily prophylaxis, respectively. The overall improvement in the incidence of the urinary infections per patient and the rate of introital colonization with enteric gram-negative bacteria was maintained after the end of prophylaxis, with a mean incidence of infections of 0.44 per patient (occurring in 34% of the total patient population), while 36% of all women had abnormal introital colonization. CONCLUSIONS Long-term post-intercourse prophylaxis with ciprofloxacin proved to be equally effective as daily prophylaxis, and the major advantage of the former therapy was use of only a third of the amount of drug consumed in daily prophylaxis.

Intravesical bacillus Calmette-Guerin immunoprophylaxis of superficial bladder cancer : results of a controlled prospective trial with modified treatment schedule

A controlled prospective trial on 94 patients evaluated the efficacy of intravesical Pasteur strain bacillus Calmette-Guerin (BCG) administration as prophylaxis against tumor recurrences after complete endoscopic resection of superficial bladder cancer. The treatment schedule, consisting of an initial 6-week course of instillations and a single quarterly maintenance dose to the responders, was modified to those of the latter who were at high risk for recurrence and who received an additional separate 4-week course of therapy. The percentage of the patients treated prophylactically with BCG and who remained free of recurrences (68%, mean followup 33.8 months) was significantly higher than that of the controls who underwent transurethral resection only (41%, mean followup 30.2 months). In terms of relative risk of recurrences, recurrence rate per 100 patient-months and disease-free interval, comparisons between the 2 groups of patients revealed a significant benefit for the BCG group overall as for those subjects having stages Ta and T1 tumors, multifocal tumors, a history of disease, and grades 2 and 3 carcinoma. Drug-induced toxicity was acceptable. Our study suggests that our modified treatment protocol is notably safe and effective against recurrent superficial bladder cancer.

COMPLICATIONS RELATED TO DIFFERENT CONTINENCE MECHANISMS IN ILEOCECAL RESERVOIRS

PURPOSE We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir. MATERIALS AND METHODS From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus. RESULTS In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple. CONCLUSIONS In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Epididymitis: Aspects Concerning Etiology and Treatment

Extended microbiological studies were performed on 49 patients with acute or chronic epididymitis, including bacteriology of epididymal specimens in cases of scrotal surgery. In no patient had instrumentation or catheterization resulted in epididymitis. The microbiological data showed a prevalence of Chlamydia trachomatis epididymal infections in men less than 40 years old, whereas common urinary tract pathogens prevailed in older patients. Cultures of urethral swabs and midstream urine provided reliable information on the type of microorganism that caused epididymitis. Ofloxacin, an antibiotic of the new quinolone group, was proved to be highly effective in the treatment of acute and chronic bacterial as well as chlamydial epididymitis.

Ten Years’ Experience with the Submucosally Embedded in situ Appendix in Continent Cutaneous Diversion

Objective: To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs. Material and Methods: Between November 1990 and June 1999 an ileocecal reservoir with appendico–umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9–82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol. Results: There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow–up of 60 months all patients are continent day and night. Conclusion: Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

Primary endourologic re-establishment of urethal continuity after disruption of prostatomembranous urethra

A new technique for the early management of traumatic disruption of the prostatomembranous urethra has been used in 4 consecutive young patients. Urethral realignment by stenting the injured urethra with a catheter was achieved by combined urethroscopy and suprapubic instrumentation one to three days after the injury. We describe herein our experience with this technique and we suggest that it could be a valuable alternative in posterior urethral repair.

Intravesical Instillations of 4-EPI-Doxorubicin (Epirubicin) in the Prophylactic Treatment of Superficial Bladder Cancer: Results of a Controlled Prospective Study

A controlled prospective study in 65 patients was done to evaluate the efficacy of intravesical epirubicin administration as prophylactic treatment in regard to the pattern of tumor recurrences after complete endoscopic resection of superficial transitional cell carcinoma of the bladder. Intravesical instillations of the drug were given weekly for 6 consecutive weeks and to the responders an intermittent maintenance therapy was administered for the first 2 years after each followup examination. Of the patients treated prophylactically with epirubicin 37% had recurrence within a total of 1,136 patient-months compared to 55% of the controls who were followed for a total of 436 months, a difference that was not statistically significant (p greater than 0.05). However, examining the results in another manner, the control patients demonstrated a significantly shorter mean interval to recurrence and higher recurrent tumor rate per 100 patient-months. To clarify further the efficacy of epirubicin therapy, comparisons of the treatment outcome according to several tumor factors were done. These comparisons revealed a significant benefit for those who received epirubicin with respect to history of tumor recurrences and multiplicity at presentation. Drug-induced toxicity was acceptable. Our study suggests that epirubicin is safe and effective against the recurrence of superficial bladder cancer.

THE INHIBITION OF CALCIUM OXALATE MONOHYDRATE CRYSTAL GROWTH BY MALEIC ACID COPOLYMERS

The crystallization of calcium oxalate monohydrate (COM) was investigated at conditions of constant supersaturation both in the absence and in the presence of synthetic maleic acid copolymers at 37C, 0.15 M NaCl. The dependence of the rates of COM crystallization in the absence of inhibitors was found to be second order at low and first order at higher supersaturations suggesting a surface diffusion controlled mechanism. The presence of all copolymers tested at concentration levels up to 5 ppm retarded the rates of COM crystal growth up to 90%. The decrease of the COM crystal growth rates by the polymers depended on the nature of the comonomer polymerized with maleic acid and the order of inhibition was found to be vinyl acetate > N-vinylpyrrolidone > styrene. Taking into consideration kinetics data published in the literature concerning the inhibition of COM crystal growth, it is suggested that molecular weight also plays a role, with more inhibition at higher molecular weights. The morphology of the COM crystals grown was unaffected yet the crystals growing at lower rates in the presence of the copolymers were larger and their size more uniform. It is concluded that maleic acid copolymers are strong inhibitors of the crystallization of COM, the inhibitory activity being more pronounced in the case of the linear copolymers.

Intravesical Bacillus Calmette-Guérin versus Epirubicin in the Prophylaxis of Recurrent and/or Multiple Superficial Bladder Tumours

A prospective, randomized trial was conducted to evaluate and compare the effects of modified adjuvant intravesical bacillus Calmette-Guérin (BCG) and epirubicin regimens in patients with superficial bladder cancer. One hundred thirty-two individuals with recurrent and/or multiple neoplasms, i.e. at high risk for tumour recurrence and progression, were enrolled. After complete transurethral resection of their tumours, the patients received a 6-week course of BCG instillations or an early 4-week course of epirubicin instillations as their initial therapy. Those with stage Ta and grade 1 neoplasms who remained free of recurrences received maintenance therapy consisting of single quarterly instillations. However, for those with stage T1 cancer of any grade or stage Ta of grade 2 or 3 neoplasms who also remained free of recurrences, the treatment schedules were modified: they received, instead of single maintenance doses, 3 weekly instillations of epirubicin at months 3 and 6 of follow-up, or a 3-week course of BCG at month 6 of follow-up. The recurrence-free rates did not differ significantly between the two study groups (44% for epirubicin versus 55% for BCG), for an identical median follow-up of 43 months. However, in terms of relative risk of recurrences, disease-free intervals and recurrence rate per 100 patient-months, a significant benefit in favour of BCG when compared with epirubicin was demonstrated in patients who had stage T1 or grade 3 neoplasms.

Primary non-Hodgkin's lymphoma of the urinary bladder

Primary non-Hodgkins lymphoma of the bladder is a rare entity and when found in such an unusual location is often difficult to distinguish from other vesical or extravesical neoplasms. Understanding of the pathobiological characteristics of this malignancy has been hampered not only because of its rarity but also by the previous confusion in its nomenclature. Factors that influence survival most strongly are the stage and the bulk of disease at presentation and the histologic classification of the tumor. We report a case of primary non-Hodgkins lymphoma of the bladder presenting as a large pelvic mass which dramatically regressed with systemic chemotherapy with simultaneous restoration of the upper dilated urinary tracts. In addition, the incidence, clinical picture, staging procedures, histologic classification and treatment modalities of this disease are reviewed.