Breast cancer risk assessment: use of complete pedigree information and the effect of misspecified ages at diagnosis of affected relatives

OBJECTIVES: To assess if there is relationship between: (i) preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction, and (ii) psychosocial adaptation after radical cystectomy for bladder cancer. PATIENTS AND METHODS: Fifty-seven consecutive patients (44 men and 13 women, mean age 62 years, range 34-81) undergoing radical cystectomy (ileal conduit urinary diversion in 17, continent cutaneous diversion in 22 and orthotopic bladder replacement in 18) were assessed preoperatively using the meta-contrast technique (MCT), a projective test to reveal individual defensive strategies. From the results the patients were classified as hypothetical 'at risk' or 'no risk' patients for postoperative psychosocial complications. An 'at risk' patient was designated as one who showed neurotic defensive strategies in coping with threats, i.e. primitive, immature or regressive strategies or even lack of defence in connection with pronounced anxiety. All patients completed a questionnaire and were interviewed; 10 questions dealt with mood, five reflecting anxiety and five the depressive states. The questionnaire and the interview were repeated 3 and 12 months, and 5 years after surgery. RESULTS: The remembered difficulties during the first month after discharge from hospital differed between the 'risk' and 'no risk' groups after 1 and 5 years. On a visual analogue scale (VAS) the 'risk' patients had very low scores (less difficulty) or very high, while the 'no risk' patients had intermediate scores. VAS score were also higher, although not significantly so, in patients using primitive defence strategies. The psychosocial situation did not differ between the groups in the first year, but at 5 years there were differences in self-esteem and interpersonal contact-seeking. High depression scores before surgery were associated with high VAS scores at 3 months when recalling the first month after discharge, but the anxiety score was not predictive. Men with orthotopic bladder replacement adapted less well throughout the 5 year follow-up. Elderly patients with stereotypy (the commonest defensive strategy at these ages) adapted relatively well to ileal conduit diversion. About 20% of patients had difficulty in accepting the postoperative situation, regardless of urinary diversion modes. CONCLUSION: The combination of defensive strategies assessed using the MCT and selected on hypothetical grounds was less discriminatory than expected for those at risk of postoperative psychosocial problems. However, those with primitive strategies apparently had a long-term risk of poor adaptation. The search for an optimal instrument for the identification of patients at risk is warranted. In this study, patients with a 'wet' stoma did not seem to fare less well than those with a continent reconstruction.     

Modification of Mitrofanoff principle for continent urinary diversion

In 1980, Mitrofanoff described a method of achieving continent urinary diversion by surgically closing the bladder neck and creating a continent catheterizable stoma from the appendix, which had been implanted in a non-refluxing manner into the bladder, or from a non-refluxing distal ureter. We describe a modification of the Mitrofanoff procedure for continent urinary diversion in 7 children in whom a standard Mitrofanoff procedure was not possible due to either body habitus or appendiceal anatomy. All 7 patients are continent both day and night. Four have required stomal revisions. Renal function has remained stable or improved in all patients. Although the revision rate was high, this modification of the Mitrofanoff principle has provided good long-term results in these patients and may be useful when patient's anatomy does not allow the creation of a standard appendicovesicostomy.     

Tissue distribution and disease manifestations of the tRNA(Lys) A-->G(8344) mitochondrial DNA mutation in a case of myoclonus epilepsy and ragged red fibres

OBJECTIVES: To evaluate the long-term influence of different types of intestinal urinary diversion on skeletal bone and its mineral content. METHODS: Densitometry was used to estimate bone mineral content, and bone biopsies were analyzed with histomorphometric technique. The study comprised 20 patients with conduit urinary diversion and 19 with cecal continent reservoir, all followed up for more than 5 years, with normal or near-normal renal function. RESULTS: Bone mineral content did not differ significantly between the patients with cecal continent urinary reservoir and those with conduit diversion or between these groups and a reference group. At the cellular level, the histomorphometric analysis revealed no defective bone mineralization or increased bone resorption in either group of patients. The trabecular bone volume was greater than normal in the reservoir group, but not in the conduit group. The appositional rate was significantly below normal in both groups of patients, but did not differ between conduit and reservoir patients. CONCLUSIONS: Subtle changes in electrolytes and acid-base homeostasis identified in adults with intestinal segments incorporated in the urinary tract and with largely normal renal function do not seem to influence bone mineralization in the long term. At the cellular level, a lower than normal appositional rate was found in the patients with conduit or continent urinary diversion. In the latter group, this finding, together with increased trabecular bone volume, may indicate a decrease of bone turnover.     

Methotrexate tolerance in patients with ileal conduits and continent diversions

BACKGROUND: Methotrexate is readily absorbed from the intestinal tract. When given to patients with urinary diversion to the intestinal tract, methotrexate may be reabsorbed into the circulation, thus increasing its serum concentration and potentially increasing its toxicity. METHODS: Forty-eight patients with transitional cell carcinoma of the urinary tract who had undergone cystectomy and either an ileal conduit or a continent diversion were evaluated for their tolerance of chemotherapy. Of the 42 evaluable patients, 23 had a continent diversion and 19 had an ileal conduit. None of the patients with the continent diversion had an indwelling Foley catheter during the course of chemotherapy. RESULTS: There were no statistically significant differences in incidence of fever or neutropenia, mucositis, dose modification, or delay in chemotherapy between the two groups. When compared with a group of patients with native bladders who received the same chemotherapy, patients with continent diversions did not have increased incidence or severe toxicity from chemotherapy. CONCLUSIONS: Patients with continent diversions tolerated chemotherapy as well as patients with ileal conduits.     

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.     

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.     

Chromosome 16 in primary prostate cancer: a microsatellite analysis

OBJECTIVES: To evaluate whether orthotopic urinary diversion is a viable option for patients undergoing cystoprostatectomy for radio-recurrent prostate cancer (RRPC). METHODS: Between 1990 and 1996, we performed 34 salvage surgeries for RRPC, including 26 radical retropubic prostatectomies and 8 cystoprostatectomies. We determined the operative and postoperative complication rates and pathologic stage for the 8 patients undergoing cystoprostatectomy. RESULTS: Of the 8 patients in whom cystoprostatectomy was performed, 5 underwent ileal conduit diversion and 3 underwent orthotopic neobladder reconstruction. There were no intraoperative complications or perioperative mortalities. In the group with orthotopic neobladder, postoperative complications included pyelonephritis in 1 patient and prolonged ileus in another. In the group with ileal conduit, no short-term complications occurred; 1 patient developed an incisional hernia on long-term follow-up. All patients with neobladder reconstruction are continent during the day. One patient wears one pad at night. The other 2 are continent at night. CONCLUSIONS: Orthotopic urinary diversion is a valid option for selected patients with RRPC who require a cystoprostatectomy. This procedure can be performed with minimal complications, resulting in good continence and good quality of life.     

A critical review of the role of definitive radiation therapy in bladder cancer

The role of radiation therapy in the management of bladder cancer continues to be controversial. Attention to the issue of response to treatment, instead of overall survival, ultimate local control and quality of life, has hampered progress in determining the optimal-treatment strategy for patients with bladder cancer. Although the heterogeneity of bladder cancer has been recognized for some time now, the trend has been to seek one cure for all, rather than to use the available modalities selectively and optimally. The use of continent urinary diversion has made cystectomy more acceptable, but no form of diversion is as satisfying as a natural, well functioning bladder. The case against definitive XRT has been built on the lack of total radiosensitivity of transitional cell carcinoma. It is interesting that the lack of total chemosensitivity of bladder cancer and total curability with surgery has not prevented those modalities from being widely used. The recognition of the systemic nature of invasive bladder cancer has appropriately led to increased attention to the control of systemic disease. However, this has led to, at times, compromised local therapy. The use of primary or adjuvant chemotherapy should not impede the pursuit of optimal local therapy in patients with bladder cancer with the emphasis on the optimal quality of life. In parallel, the goal of bladder preservation and improved quality of life should not overshadow the importance of local tumor control. Because metastatic bladder cancer currently is an almost universally lethal disease, we should optimize the use of effective treatment modalities to achieve modest improvements in cure rate. The idea that definitive radiation therapy has no role in the management of bladder cancer exists in the minds of those who hold strong convictions and see an alternative view to their own as being controversial. We believe that attention should not focus on this controversy but on the recognition of the reality that the best management of bladder cancer is a shared responsibility among the oncologists of all disciplines. With this recognition, clinical research toward improving outcome for patients with bladder cancer will move forward.     

Experience with the Mainz modification of ureterosigmoidostomy

BACKGROUND: The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion. METHODS: Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1.9-76.9 (mean 55.8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid-base balance. RESULTS: There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients. CONCLUSION: Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.     

Management of invasive carcinoma of bladder and abdominal aortic aneurysm (AAA); technique of radical total cystectomy and simultaneous AAA repair

BACKGROUND: There is no consensus on the optimal surgical treatment for patients with concomitant invasive carcinoma of bladder and abdominal aortic aneurysm (AAA). We experienced two patients who were treated successfully with simultaneous radical cystectomy and AAA repair. The techniques required for the combined procedure and case reports are discussed. PROCEDURE: The goal of the one-stage operation was to minimize the risk of graft infection without compromising postoperative morbidity and mortality secondary to carcinoma of bladder. Initially pelvic lymph node dissection and radical cystectomy were performed. We preferred retrograde cyctoprostatectomy because most of the cystectomy procedure can be performed without opening the peritoneal cavity and the extent of the retroperitoneal dissection can be minimal. A single-stoma ureterocutaneostomy was preferable urinary diversion. Urinary diversions which utilize intestine such as ileal conduit or ileal urinary reservoir may cause contamination of a graft with bowel content and should be avoided. Before or after urinary diversion, aneurysmal resection and a bifurcated graft replacement were performed. The replaced graft was wrapped with the aneurysmal wall. The major omentum was mobilized and fixed in front of the graft, thereby serving as a protective barrier of the graft. A Dacron graft which was sealed with rifampicin-bonding gelatin was used to further reduce the risk of graft infection. RESULT: Two male patients were treated with the one stage radical cystectomy and AAA repair. Single-stoma ureterocutaneostomy and bilateral ureterocutaneostomy were selected as a urinary diversion. No major postoperative complications, except for paralytic ileus in one case, were observed. CONCLUSION: Our experience and reports of others indicate that radical cystectomy and simultaneous AAA repair can be safely performed with less morbidity than staged operations for the management of concomitant invasive carcinoma of bladder and AAA.     

Ureteroileal anastomotic strictures: an innovative approach with metallic stents

PURPOSE: We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion. MATERIALS AND METHODS: We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months. RESULTS: No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement. CONCLUSIONS: We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.     

The Indiana pouch continent urinary reservoir

The right colon reservoir using a stapled plicated ileal efferent limb (Indiana continent urinary reservoir) has been demonstrated to be a reproducible durable form of continent diversion. The overall day and nocturnal continence rate of 94% compares favorably with all other forms of continent cutaneous diversion. Carefully following the technique of stapling and plicating the ileal efferent limb and ileocecal valve as described in this article nearly ensures adequate competence of the outlet valve. In the rare case in which incontinence occurs, it is almost always on the basis of high-pressure unit contractions of the reservoir. On occasion, patients who develop incontinence are observed to have high pressures within the reservoir despite complete detubularization of the right colon segment. When this problem is encountered it can be corrected successfully by adding an ileal patch augmentation to the previously detubularized reservoir. The issue of ureteral implantation in continent urinary diversions is as yet unsettled. Many authors have not used ureteral tenial tunnels and have reported a reflux rate of < 13%. Furthermore, these patients have not developed any long-term sequelae of their reflux. Although favorable results have been obtained without creating tunneled tenial reimplantation, we believe that continent cutaneous reservoirs are almost always colonized with bacteria, and an antireflux mechanism may offer protection against subsequent pyelonephritis. Closure of the reservoir traditionally has been conducted by hand at our institution; however, the development of smaller absorbable gastrointestinal anastomosis stapling devices offers the theoretic advantage of shortening the operative time. We anxiously await follow-up, including larger patient numbers and longer term follow-up of the absorbable staple technique. The use of continent cutaneous urinary diversion clearly has decreased as bladder replacement has become a more viable procedure over the past decade. Despite this, the urologic reconstructive surgeon must maintain the ability to perform continent cutaneous diversion in patients who are unwilling to accept the potential for nocturnal incontinence observed in all forms of bladder replacement as well as the patients who have ineffective sphincter mechanism or who need a urethrectomy due to their primary disease.     

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.     

Glutamate release in the nucleus tractus solitarius induced by peripheral lipopolysaccharide and interleukin-1 beta

PURPOSE: The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection. MATERIALS AND METHODS: We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification. RESULTS: Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression. CONCLUSIONS: Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.     

Helicobacter pylori and gastric lymphoma]

BACKGROUND: Continent urinary diversion may be necessary in a range of urological abnormalities. In circumstances where the standard techniques are not possible, alternative innovative techniques may be used. METHODS: In a female patient with bladder exstrophy, a continent diversion was recommended. The appendix was not available, the ureters were not suitable and a continent stoma was fashioned from an isolated segment of colon. RESULTS: The stoma proved to be continent, although it was somewhat stenotic. However, clean intermittent catheterization maintained its patency. CONCLUSIONS: A continent catheterizable stoma may be constructed from a segment of colon. The technique may be considered when other well recognized methods are not feasible.     

A case of adenocarcinoma arising in the vesical diverticulum

A 70-year-old woman presented at our hospital with the chief complaint of gross hematuria and pain on urination. Cystoscopy revealed a broad-based tumor covered with mucus on the right wall of the bladder and therefore a transurethral resection was performed. At surgery the tumor was found to arise from the diverticulum and could not be resected because of the risk of perforation. A histopathological examination disclosed adenocarcinoma including a small region of signet ring cell carcinoma. The tumor was thus diagnosed to be adenocarcinoma originating from the vesical diverticulum and total cystectomy and urinary diversion (ileal conduit) were scheduled. At operation, the carcinoma was found to have infiltrated into the cecum. The operation procedure was therefore changed to partial cystectomy and excision of the cecum in consideration of both the patient's quality of life and her overall prognosis. Although a tumor originating from the vesical diverticulum and adenocarcinoma are both considered to be factors indicating a poor prognosis, no signs of recurrence or metastasis have been detected in this patient at 26 months after the operation.     

Utility and safety of parotid gland biopsy in Sj?gren''s syndrome

OBJECTIVE: To review the results of bladder-neck reconstruction in patients with repaired bladder exstrophy and pubic diastasis. PATIENTS AND METHODS: Nine girls (mean age 7 years, range 4-17) and four boys (mean age 9 years, range 5-15) underwent a modified Young-Dees-Leadbetter bladder-neck reconstruction with augmentation cystoplasty (YDL-C). The patients were reviewed retrospectively (follow-up, 1-6 years) to assess continence, particularly in relation to the degree of pubic diastasis measured on an appropriate abdominal radiograph. RESULTS: Ten patients were continent; seven girls and one boy are managed by clean intermittent catheterization (CIC) and one girl and one boy void normally. One girl who would not allow CIC and one boy in whom CIC was not possible are incontinent and are scheduled for construction of a continent diversion. One incontinent boy who also would not allow CIC was lost to follow-up. Public diastasis had no bearing on the surgical results, the 10 continent patients having diastasis ranging from 4 to 9 cm (mean 5.5 cm) and the incontinent patients a diastasis of 3.4 and 6.5 cm (mean 4.5 cm). CONCLUSION: Young-Dees-Leadbetter bladder-neck reconstruction with augmentation cystoplasty is a satisfactory operation in patients with bladder exstrophy. We believe that the rate of continence reflected a competent tubularization with an adequate bladder capacity and assured bladder emptying. A closed pelvis with approximated public bones is not necessary to achieve this objective.     

Malone antegrade continence enema for adults with neurogenic bowel disease

PURPOSE: We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS: Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS: Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS: Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.