The natural history of condyloma in children

OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.     

The adrenergic, cholinergic and NANC nerve-mediated contractions of the female rabbit bladder neck and proximal, medial and distal urethra

1. The nerve-mediated contraction of the female rabbit bladder neck and different portions of the urethra (proximal, medial and distal) was studied in vitro by electrical stimulation (50 V, 30 Hz, 0.05 ms width, trains of 5 s every 5 min) by use of a superfusion system. 2. The amplitude (Emax) and the duration (Dmax) of the stimulated contraction were studied in the four tissues. The Emax value was significantly higher in distal urethra (2.07+/-0.15 g) compared to the bladder neck (1.08+/-0.10 g), proximal urethra (0.73+/-0.07 g) and medial urethra (0.87+/-0.07 g). In contrast, the Dmax value appeared slightly but significantly lower (P<0.05) in distal urethra (68.5+/-2.3 s) than in bladder neck (76.7+/-6.0 s), proximal urethra (84.5+/-5.0 s) and medial urethra (81.3+/-3.5 s). 3. Cocaine (1 microM) significantly increased the basal Emax values in medial and distal urethra and the basal Dmax values in the four tissues. 4. Prazosin (1 microM) significantly reduced E max value in proximal, medial and distal urethra and Dmax value in bladder neck and proximal urethra. Atropine (1 microM) also significantly reduced Emax values in bladder neck and proximal urethra and reduced Dmax value in bladder neck, but not in other tissues. Yohimbine (0.1 microM) was devoid of effect in the four tissues. 5. The association of prazosin (1 microM) and atropine (1 microM) did not modify the Emax and the Dmax values of the electrically-induced contractions, except in proximal urethra and in bladder neck where an additive inhibitory effect (on Emax only) was observed compared to prazosin and atropine alone. 6. The residual contractile response after combined treatment with prazosin and atropine was significantly diminished by tetrodotoxin (TTX; 1 microM) but not completely abolished. These NANC contractions were insensitive to P2X-purinoceptor desensitization by continuous tissue perfusion with alpha,beta-methylene ATP (30 microM). 7. These results demonstrate that bladder neck and proximal urethra are mainly innervated by the parasympathetic nervous system, whereas medial and distal urethras are to a greater extent under the control of the sympathetic innervation. The residual responses, insensitive to prazosin and atropine, may indicate a NANC innervation in the four tissues. However, the nature of the NANC neurotransmitter remains to be identified.     

Muscular urinary sphincter: electrically stimulated myoplasty for functional sphincter reconstruction

PURPOSE: To reconstruct an electrically stimulated muscular urinary sphincter (MUS) using a tailored gracilis muscle free flap with intact nerve. MATERIALS AND METHODS: Unilateral surgically tailored gracilis muscle free flaps were transferred into the pelvis in eight dogs, leaving the obturator nerve intact. The muscle's pedicle vessels were anastomosed to the inferior epigastric artery and vein in the pelvis and the muscle was wrapped around the bladder neck. Electrodes were inserted into the MUS and connected to a programmable pulse generator. After 8 weeks of training the MUS, the pulse generator was programmed to be "on" for 4 hours and "off' for 15 minutes in a continuous cycle. Urodynamic studies were performed periodically, and at the end of the experiment the MUS and proximal urethra were harvested for histology. Three control dogs had sham operations. RESULTS: All MUS's functioned well following the procedure. Histology of the MUS/urethra complex showed no evidence of stricture. Except for one dog, all urethras were easily catheterized. CONCLUSIONS: This electrically stimulated innervated free-flap MUS technique effectively increases bladder outlet resistance without producing urethral obstruction.     

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.     

Intranasal steroids and septum perforation--an overlooked complication? A description of the course of events and a discussion of the causes

One of urodynamic diagnostic methods is visualisation of the bladder neck opening which enables seeing the difference between internal and external urethral sphincter disfunction. Micturition video cysto-urethrography with X-rays makes possible to carry on such examinations, but it requires catheterisation which makes the method invasive. My purpose is to replace this examination by dynamic functional evaluation of the internal urethral sphincter during transrectal ultrasonography. During 10 routine transrectal ultrasound examinations of the prostate, patients were asked to urinate. During examination changes in configuration of the bladder neck and prostatic urethra were observed. Two patients could not urinate in horizontal position. In the rest of the patients very clear pictures showing changes in the shape and dimensions of the urethra during urination, were achieved. They were much more clear in comparison with X-ray video cystourethrography. Transrectal sonography is a perfect technique of the visualisation of the bladder neck and prostatic urethra during urination. The suggested method should be included into the urodynamic examinations.     

Value of transrectal ultrasonography in the assessment of failures of stress urinary incontinence surgery in women

OBJECTIVES: To describe the role of transrectal ultrasonography as an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. METHODS: The means of independent samples of transrectal ultrasound parameters of two groups of patients (group I, patients who were continent after surgery; group II, patients who remained incontinent after surgery) were compared. RESULTS: Patients who were continent after surgery showed scanty caudal and dorsal mobility of the bladder neck and proximal urethra during the periods of increased intraabdominal pressure. The US finding in this group of patients is characterized by a funnel surrounding the bladder neck and the proximal urethra. The existence of an intrinsically incompetent sphincter can also be determined with this technique. CONCLUSIONS: Transrectal ultrasonography constitutes an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. It permitis determining whether incontinence is due to a failed procedure, the existence of an intrinsically incompetent sphincter, or whether other causes of incontinence should be investigated.     

Anatomical mechanisms of continence in man

According to classical concepts, the role of the bladder sphincteric apparatus is to contain without weakness and to expel without effort. Continence without dysuria is the result of: biomechanical properties of the bladder wall which confer: viscoelasticity accounting for its compliance, contractility allowing expulsion of its contents. The action of bladder neck structures and passive urethral mechanisms which, under normal conditions, are practically sufficient to ensure passive continence. Muscle fibre tone collapses the urethra during the continence phase and closes the bladder neck by creating vesicourethral angulation. The arrangement of these muscle fibres in the bladder neck and urethra accounts for the sphincter function over the entire length of these two structures. The external sphincter composed of striated muscle fibres derived from perineal muscles, which are amenable to retraining. The main role of the sphincter under normal conditions is to oppose an unwanted bladder contraction or to rapidly interrupt ongoing micturition and it only has a relatively limited role in passive continence. It is particularly important after prostatic surgery, either for benign prostatic hyperplasia or for cancer, when the striated sphincter remains the only structure able to oppose the pressure forces which tend to expel urine from the bladder.     

Correlation of the cystoscopic appearance and functional integrity of the female urethral sphincteric mechanism

OBJECTIVES: Urologists in the past, and many today, rely on the cystoscopic appearance of the female urethra as a guide to its functional integrity. To assess the accuracy of this approach better, we compared the cystoscopic appearance of the bladder neck and proximal urethra to the functional integrity of this mechanism during videourodynamic studies. METHODS: One hundred consecutive videourodynamic studies were reviewed on female patients with more complex types of urinary incontinence. Reports of their cystoscopic examinations were reviewed and results compared. RESULTS: Significant dysfunction of the intrinsic mechanism was noted in 36% of the patients (26% moderate dysfunction and 10% severe dysfunction) on video studies. Cystoscopy underestimated these deficits 74% and 44% of the time, respectively, in the moderate and severe dysfunction groups. CONCLUSIONS: We conclude that the cystoscopic appearance of the bladder neck proximal urethra cannot predict the functional integrity of this mechanism.     

Splenorenal shunt blood flow by transit-time ultrasound as an index of collateral circulation in portal hypertensive rats

OBJECTIVE: The purpose of this study was to explore the role of sonography for women with urethral symptoms and a suspected urethral diverticulum. SUBJECTS AND METHODS: Nineteen women with urethral symptoms underwent voiding cystourethrography (VCUG) and transvaginal, transperineal, and urethral sonography (using a catheter-based transducer). VCUGs and sonograms were evaluated for diverticula, defined on sonography by direct visualization of the neck connecting the periurethral sac with the urethral lumen. The diverticular neck, size, location, and shape were noted. Lesions revealed by sonography as not connected to the urethra were also noted. RESULTS: Of 19 women, 14 had urethral diverticula and one had two diverticula, for a total of 15 diverticula. On sonography the diverticula ranged in diameter from 2 mm to 5 cm. Both sonography and VCUG showed 13 of the 15 diverticula. In addition, sonography revealed two infected periurethral cysts, a periurethral leiomyoma, a diffuse urethritis, and scarring or deformity of one patient's urethra from a prior diverticulectomy. On sonography, eight of the 13 diverticula wrapped around more than 50% of the urethral circumference. The neck was precisely seen (by definition) in 13 of 15 diverticula on sonography and in two of 13 diverticula on VCUG. CONCLUSION: Sonography is useful in this group of women with urethral symptoms and suspected urethral diverticula. It provides information on the extent and location of the diverticular neck, both of which are important in surgical excision. Also, sonography provides information on lesions not connected to the urethra. Sonography may prove useful in a broader group of women with urethral symptomatology.     

Membrano-bulbo-urethral junction stenosis. Posterior urethra obstruction due to extreme caliber disproportion in the male urethra

OBJECTIVE: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described. SUBJECTS: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG). RESULTS: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis. CONCLUSION: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.     

Congenital urethral strictures

We present 12 patients with presumed congenital urethral stricture (mean age at diagnosis 20 years). They complained of various urological symptoms, including dysuria, transient urinary retention, urgency and reduced flow. The time from onset of symptoms to diagnosis averaged 18 months. The strictures were presumed congenital because no patient had a history of urethral infection or of instrumentation, and all the strictures were at the proximal bulbar urethra, as has been described for congenital, bulbar, urethral stricture. We treated 5 patients initially by internal urethrotomy, of whom 2 required transurethral dilatation at follow-up. 7 others were treated initially by transurethral dilatation, 4 of whom required more than 1 treatment. Follow-up has averaged 21 months. In 8 of 10 patients the maximal urinary flow at latest follow-up is greater than 20 ml/sec.     

Echographic diagnosis of female urethral diverticulum

OBJECTIVE: To describe the utility of transrectal ultrasound as an alternative imaging technique in the diagnosis of diverticulum of the female urethra. METHODS/RESULTS: A 35-year-old female that had been initially diagnosed as having a benign tumor of the vagina is described. The voiding cystogram, positive pressure urethrography with a double balloon catheter and urethroscopy were falsely negative for urethral diverticulum of the female urethra. Subsequent evaluation by transrectal ultrasound disclosed on oval-shaped, anechoic lesion located posteriorly to base of the bladder. CONCLUSIONS: Transrectal ultrasound could be the diagnostic imaging technique of choice in patients suspected as having diverticulum of the female urethra.     

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.     

Antithrombogenic activity of blood vessel walls in the pathogenesis of metastasis in tumor-bearing animals]

Ho-YAG laser (Medoptotech) operates in impulse regimen with transmission of radiation along the fiber 400-600 microns in diameter (mean power 12 W, impulse rate 1-15 Hz, energy of 1 impulse 0.7-1.5 J, its duration 300 microseconds. These parameters provide the effect of intensive biotissue evaporation, dissection of contact tissue, disintegration of concrements, hemostasis. Ho-YAG laser was employed for treatment of 8 patients with urethral polyp, 4 with stricture of the bladder neck and urethra, 5 with prostatic adenoma, 12 with bladder tumor, 10 with ureterolith, 5 with uroliths, 4 with penile lesions, 2 with ureteral stricture, 4 with ureterocele. Ho-YAG laser was used primarily for endoscopic interventions. Its use for open surgery is also promising. Further practical experience with Ho-YAG laser will provide additional information on its indications in urological diseases.     

Metabolism of quinine in children with global malnutrition

OBJECTIVE: To evaluate the frequency, predictive parameters and prognosis of urethral recurrence after cystoprostatectomy for urothelial bladder cancer. MATERIAL AND METHODS: From 1989 to 1994, 8 of a series of 185 patients (4.3%) treated by cystoprostatectomy for bladder carcinoma between 1988 and 1993 developed urethral recurrence revealed by urethral bleeding, with a follow-up of 6 to 36 months (m = 16). RESULTS: The initial bladder tumour was localized in 3 cases and multifocal in 5 cases. The posterior urethra was not involved in 5 cases, but presented lesions of CIS in 1 case and neoplastic infiltration also involving the prostate in 2 cases. These recurrences were treated by urethrectomy, as first-line treatment in 7 cases and after failure of endoscopic treatment in 1 case. A balanic recurrence required distal penectomy following insufficient urethral resection. The course was very rapidly unfavourable for 3 patients with generalized cancer and an intercurrent disease was fatal in 1 other case. With a follow-up of 12 to 44 months (m = 26), 4 patients are alive with no obvious signs of disease progression. CONCLUSION: The indications for prophylactic urethrectomy can be reserved to patients with positive urethral resection margins, provided all other cases are submitted to strict surveillance. In the context of a replacement bladder, it is essential to exclude neoplastic involvement of the posterior urethra or prostate, especially in patients previously treated by intravesical instillations.     

A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men

OBJECTIVE: To examine whether transrectal voiding ultrasonography (TRVUS) can evaluate voiding movement in men with dysfunctional voiding. METHODS: Ninety-nine consecutive men complaining of voiding difficulties without benign prostatic hyperplasia, prostatic cancer, severe bladder neck contracture and urethral stricture received uroflowmetry and TRVUS. Those who had abnormal findings on both uroflowmetry and TRVUS underwent subsequent cystometry combined with electromyography (EMG) to confirm the presence of dysfunctional voiding. RESULTS: Uroflowmetry indicated abnormal findings in 31 of the 99 patients, and TRVUS demonstrated abnormal movements of the posterior urethra during voiding in all of these 31 patients and 11 of the other 68 patients whose uroflowmetry did not indicate abnormality. TRVUS findings of the former 31 were divided into type E (the external urethral sphincter closed or intermittently opened while the bladder neck manifested an opening movement of > 7 mm during voiding in 20) and type I (both the bladder neck and external urethral sphincter manifested an intermittent movement of < 7 mm in 11). Subsequent cystometry combined with EMG in the 31 patients who had abnormal findings on both uroflowmetry and TRVUS revealed overactivity of the external urethral sphincter (OS) and underactivity of the detrusor (UD) in 85 and 35% of type-E group and 55 and 73% of type-I group, respectively. Type E included significantly more OS without UD than type I (65 vs. 18%; p = 0.0233). All of type-E (20/20) and 91% of type-I (10/11) patients had voiding difficulty which resulted from either OS or UD, while a very limited number of patients (4/31) manifested neurological symptoms such as paraplegia except for voiding difficulties. CONCLUSIONS: Both uroflowmetry and TRVUS are easy and useful methods to evaluate dysfunctional voiding in men, especially when neural disorders or organic obstruction of the lower urinary tract are not apparent.     

Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE: We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death. MATERIALS AND METHODS: The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented. RESULTS: Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death. CONCLUSIONS: The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

Genetic association of bovine lymphocyte antigen DRB3 alleles with immunological traits of Holstein cattle

PURPOSE: Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients. MATERIALS AND METHODS: Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70). RESULTS: There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming. CONCLUSIONS: The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.     

The urethral resistance to rapid dilation: an analysis of the effect of autonomic receptor stimulation and blockade and of pudendal nerve blockade in healthy females

The urethral closure function is based upon permanently as well as adjunctively acting closure forces during rest and stress episodes, respectively. During urine ingression intra- and peri-urethral structures are suddenly stretched resulting in a pressure response which strengthens the closure function by sustaining the resistance to dilatation of the urethra. A method for measurement of the resistance to rapid urethral dilatation was used to evaluate the influence of noradrenaline, prazosin, terbutaline, propranolol, carbachol, and atropine, as well as bilateral pudendal nerve blockades in 40 healthy women. The drugs caused no significant change in the urethral resistance to dilatation, whereas the pudendal blockade produced a significant (p < 0.05) reduction at the bladder neck and in the high pressure zone. Although a quantitative assessment of their contribution cannot be obtained from this study, it may be concluded that the striated muscles innervated by the pudendal nerve are of major importance for the urethral resistance to dilatation.     

The ileal neobladder to the female urethra

In the author's opinion, in the properly selected woman undergoing radical cystectomy for transitional cell carcinoma of the bladder, the ileal neobladder to the female urethra is a viable option. Ten years of experience with 23 patients have led to a nerve and urethral support cystectomy technique with the ileal neobladder anastomosed to the proximal urethra. Even then, however, retention in 20% of patients rather than the expected incontinence is the critical issue. Incontinence has never been a problem. The advent of orthotopic lower urinary reconstruction in women is a major achievement in the evolution of urinary diversion. With our increasing understanding of the continence mechanism in women and with increasing evidence that the female urethra can be safely preserved after cystectomy, orthotopic lower urinary tract reconstruction by the ileal neobladder can now be offered safely not only to men but also to women undergoing cystectomy with superb functional results.