Rectus abdominis muscle flap (RAMF) technique for the management of bladder exstrophies: late clinical outcome and urodynamic findings

OBJECTIVE: To investigate the efficacy of the rectus abdominis muscle flap (RAMF) technique for the closure and augmentation of small, non-compliant bladder exstrophies. PATIENTS AND METHODS: The RAMF technique was used in two girls and two boys (mean age at operation, 31.7 months, range 3-72) with bladder exstrophy. The clinical outcome and urodynamics were assessed during a follow-up of 29 months to 6 years (mean 49.2 months) and included imaging, cystoscopy, biochemical and microbiological studies. RESULTS: There were no urinary tract infections, metabolic problems or electrolyte disturbances and kidney function remained normal in all patients. Radiography confirmed intact function and anatomy of the urinary tract and cystoscopy showed complete coverage of the inner peritoneal layer of RAMF with uroepithelium. No stone formation or mucus production were detected. Currently, three patients void using clean intermittent catheterization through the native urethra and the fourth through an appendiceal Mitrofanoff valve. However, the bladder volume was insufficient at the late follow-up and three patients required bladder augmentation. CONCLUSIONS: The RAMF technique is a good alternative for closing bladder exstrophies and achieves an increase in bladder capacity; however, although there is a mild improvement in bladder capacity and compliance. RAMF should not be used as a bladder augmentation procedure. The technique is indicated in the closure of large bladder defects, bladder exstrophies with small, inelastic, non-compliant bladder remnants and failed primary closures.     

Tissue type plasminogen activator antigen in urine of patients with bladder cancer

In urine of 25 patients with bladder carcinoma the antigen of tissue type plasminogen activator (t-PA) was assessed. The level of t-PA was much higher in patients with bladder carcinoma in comparison with a control group. We also analyzed the level of t-PA between patients with superficial and invasive bladder carcinoma the level of t-PA was higher. In conclusion, there is t-PA in urine of patients with bladder carcinoma and its level is correlated with staging of neoplasm.     

Urodynamic correlates of resolution of reflux in meningomyelocele patients

PURPOSE: Resolution of reflux in meningomyelocele patients is a reflection of improved bladder storage. We correlated resolution of reflux with changes observed in sequential urodynamic studies. MATERIALS AND METHODS: The study included 27 children with meningomyelocele born between 1975 and 1985 who presented with or developed vesicoureteral reflux. Resolution of reflux was observed during the 10-year followup period as they were treated with a regimen of clean intermittent catheterization and pharmaco-therapy. Urodynamic studies were performed when vesicoureteral reflux was present and subsequent to its resolution. The urodynamic parameters compared in the 2 studies included bladder capacity, pressure specific bladder volume, bladder compliance and leak point pressure. RESULTS: Significant increases in bladder capacity, pressure specific bladder volume and bladder compliance were noted. Leak point pressure appeared to be decreased subsequent to resolution of reflux. CONCLUSIONS: Resolution of reflux in meningomyelocele patients correlates with changes in parameters of bladder storage observed on sequential urodynamic studies.     

Carcino-embryonic antigen activity in urine of patients with bladder carcinoma. Clinical evaluation of carcino-embryonic antigen. II

This paper deals with the study of CEA levels in urine from healthy control subjects, of patients with bladder carcinoma or previous bladder carcinoma, and other groups of patients. In 53% of the patients with bladder carcinoma and without urinary infection, urinary CEA was increased. There were no false positive results. It is concluded that urinary CEA is a valuable aid in the detection of malignant tumour growth in the bladder. The results are compared with several tumour parameters, e.g. tumour size, stage of disease and histological parameters. Evidence is presented that CEA in infected urine is not produced by bacteria and that, like soluble vaginal excretory products, this substance has antigenic groupings in common with CEA from bladder tumours.     

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.     

Clinical vs haemodynamic response to drugs in portal hypertension

OBJECTIVE: Intercellular adhesion molecule-1 (ICAM-1) is known to play a role in immunity against bladder cancer and can be detected in the supernatants of cultured bladder cancer cells that constitutively express ICAM-1. This study was performed to examine the relevance of the ICAM-1 urine test in patients with bladder cancer. METHODS: A total of 53 patients with bladder carcinoma, 35 with history of bladder cancer, and 30 normal control subjects were included in this analysis. Urinary ICAM-1 (ulCAM-1) levels were measured by immunoassay and corrected for hydration status. RESULTS: Levels of ulCAM-1 were significantly elevated in patients with bladder cancer or those at tumor-free status compared with normal control subjects (P=0.001). However, there was no apparent difference between the two groups of urothelial disorders (P >0.1). ulCAM-1 did not correlate with clinicopathologic variables of bladder cancer or patient outcome (P >0.1). Six patients at tumor-free status had multiple ulCAM-1 determinations during the study period. Three of these 6 patients had elevated ulCAM-1 levels and proved to have recurrent tumors; 3 of the 6 had stable ulCAM-1 levels and were still free of disease. CONCLUSIONS: Our results suggest that urinary excretion of ICAM-1 is elevated in the early stage of bladder carcinogenesis, but is independent of biologic properties of bladder cancer. Serial monitoring of ulCAM-1 may be helpful in selecting patients who are at risk of tumor recurrence.     

Usefulness of bladder auto-augmentation in neurogenic bladder: a case report

A 41-year-old male with myelomenigocele underwent a bladder auto-augmentation and endoscopic collagen injections. He has been performing self intermittent catheterization for 10 years but urinary incontinence remained unchanged. Furthermore, he suffered from recurrent pyelonephritis due to the left vesicoureteral reflux. A preoperative fluoroscopic urodynamic study showed a poorly compliant bladder with the maximal bladder capacity of 200 ml at 60 cmH2O. The left vesicoureteral reflux was observed at 10 cmH2O. The low compliant bladder was treated with the bladder autoaugmentation and the left vesicoureteral reflux was treated with the endoscopic subureteral injection of collagen 5 months after the previous operation. A fluoroscopic urodynamic study 6 months postoperatively showed the increase of the maximal bladder capacity of 300 ml at 18 cmH2O and the reflux disappeared completely. The endoscopic periurethral injections of collagen improved his persisting urinary incontinence. In patient with neurogenic bladder having a lot of clinical problems, bladder auto-augmentation is less invasive and offers many advantages over enterocystoplasy.     

Unbiased and efficient estimation of bladder volume with MR imaging

Almost all methods of measuring residual volume of urine in the bladder of patients undergoing urologic assessment are biased to an unknown extent. The authors describe the application of an unbiased stereologic technique for estimating the volume of bladder urine known as the Cavalieri method. The method requires imaging of a series of systematic (ie, equally spaced) parallel sections through the bladder. Such data can be conveniently obtained with magnetic resonance (MR) imaging. If sampling begins at a position randomly chosen within the distance corresponding to the section interval, bladder volume is estimated without bias as the sum of the areas of the bladder sections on the images multiplied by the section interval. Computer-aided point-counting techniques represent an efficient means of obtaining the required section area estimates. Optimum sectioning and point counting densities for estimating bladder volume were established by analyzing detailed data sets obtained in five volunteers. It was shown that if an average of only 20 points were counted in each of only five systematic sections through the bladder, the volume of bladder urine was estimated with a coefficient of error of about 5%. By studying these five volunteers and an additional 13 with MR imaging and the Cavalieri method, the authors showed that the difference between the volume of urine in the bladder before and after micturition is unbiased (ie, shows no systematic difference) with respect to the volume of urine voided by the subjects.     

Nitric oxide (NO) pathway and locomotor hyperactivity towards dopaminomimetics in rats

The incidence of bladder cancer continues to increase, with an estimated 53,000 new cases diagnosed in the United States in 1996-90% of which are transitional cell carcinomas. The male-to-female ratio is 3:1. A number of etiological factors are associated with the development of bladder cancer, but in industrialized countries, cigarette smoking is the most important. Specific chemicals have also been identified as causing bladder cancer, as have a number of occupational exposures to less well-defined specific agents. Treatment with cytostatic drugs, especially cyclophosphamide, is associated with increased risk of bladder cancer, as is treatment with radiotherapy for uterine cancer. In developing countries, especially in the Middle East and parts of Africa, infections with members of the genus Schistosoma are responsible for a high incidence of bladder cancer-75% of which are squamous cell carcinomas. Arsenic has been indicated as a bladder carcinogen in Argentina, Chile, and Taiwan. The reason for the high incidence of urinary tract cancer in individuals suffering from Balkan nephropathy has yet to be determined. A careful history of patients with bladder cancer is an important and useful process in helping to identify causal factor and, in more than one-half the cases, a known relationship is found. Bladder cancer is a potentially preventable disease, with a significant morbidity and mortality in many parts of the world.     

Xenon-133 resorption in urinary bladder: functional diagnosis of bladder epithelium

The examination of resorption from the urinary bladder had previously been restricted almost exclusively to animal research, since, as a rule, a separation of the bladder from the urinary tract is required. If this is not done, the resorbed test substance quickly finds its way back into the bladder. More than 95 per cent of the xenon which has been resorbed from the bladder becomes eliminated through the lungs. The detection and measurement of xenon in the exhaled air enables one to conduct, in a relatively simple fashion, urinary bladder resorption research using human subjects. Studies based on 141 patients showed that the xenon exhalation tests currently represent the most sensitive and exact method for detecting and determining the nature of inflammatory diseases of the urinary bladder. With a number of so-called "irritable bladder" cases it became clear that functional disorders of the bladder epithelium could be present without any evidence of associated morphologic changes. With radiogenic treatment of tumors in the lower pelvic region one experiences an increase in bladder resorption with increased exposure to radiation. There exists, as it were, a linear correlation between the radiation dosage and the degree of resorption from the urinary bladder. Three months after terminating radiotherapy one can detect, as a rule, only a negligible increase in resorption. If at this time the rate of xenon resorption still remains clearly high, one must reckon with permanent radiation damage of the bladder, insofar as it proves unsuccessful to eliminate the cause of cystitis.     

Eosinophilic cystitis: a rare case which presented as an invasive bladder tumor

Eosinophilic cystitis is a rare inflammatory lesion of the bladder of unknown etiology. It can be confused clinically and cytoscopically with invasive bladder cancer. We report a case in which the lesion presented as an invasive bladder tumor and we discuss the literature in brief.     

Plastic repair of the urinary bladder

Clinical observations of 76 patients in whom an artifical urinary bladder was constructed from the rectum are presented. 52 patients were operated upon for cancer of the urinary bladder, total papillomatosis, a metastasis of uterine cancer in the bladder, cancer of the sigmoid with the urinary bladder involvement, sarcoma and cancer of the prostate with the bladder involvement. 17 patients were operated upon for extrophy, 7 -- for cancer of the urethra. An isolation of the rectum is followed by ligation of the upper rectal and vein. Fifteen patients died postoperatively due to peritonitis (6), ascending infection of the urinary tract (4), postoperative shock (I), phlegmon of the minor pelvis (I). In late postoperative period an artificial urinary bladder provides for reservoir and excretory functions.     

Laparoscopy in the management of diaphragmatic rupture due to blunt trauma

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH2O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH2O), reimplantation with bladder augmentation is recommended.     

Interphase cytogenetic diagnosis of bladder cancer on cells from urine and bladder washing

In order to determine the value of fluorescence in situ hybridization (FISH) in the diagnosis and follow-up of bladder cancer interphase cytogenetics was performed on cells from urine and bladder washings. 50 ml of urine or bladder washings were collected. FISH was carried out using centromere probes for chromosomes 7, 8, 9 and 12 according to standard protocols. In each case 100 cell nuclei were analysed. Fifty-four samples from urine and 67 samples from bladder washing were analysed by FISH in comparison with results obtained by conventional cytology. Sensitivity of detection of tumor cells by FISH was 68.5% in urine and 63% in bladder washings regardless of tumor stage and grade. Sensitivity obtained by conventional cytology was 50% in urine and 77.3% in bladder washings. FISH on cells from urine samples is an effective complement to the standard urine cytology. Using centromere probes this approach is characterized by high specificity and sensitivity in tumors with T-category higher than pTa and grade higher than G1.     

Effectiveness of the massive campaign for immunization against Meningococcus (serogroup C) in the Autonomic Community of the Basque Province

A prospective study was conducted on 27 dogs with recurrent urinary tract infections (UTIs) and urolithiasis. Four sampling methods (i.e., urine obtained by cystocentesis, bladder mucosal swab, bladder mucosal biopsy, and urolith) were compared to identify UTI. Identical culture results were obtained from urine collected by cystocentesis and from the swab of bladder mucosa. In the presence of a positive urine culture, the same organism also was cultured from the bladder mucosal biopsy and urolith. However, in the presence of a negative urine culture, an organism was cultured from the bladder mucosal biopsy or the urolith in 18.5% of the cases. Therefore, when the culture from urine obtained by cystocentesis is negative, it is recommended that aerobic cultures of a bladder mucosal biopsy and a urolith be performed in cases of urolithiasis.     

Bladder cancer in patients with multiple sclerosis treated with cyclophosphamide

PURPOSE: We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis. RESULTS: Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury. CONCLUSIONS: These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.     

Laboratory testing may not glitter like gold

Diverticula of the gall bladder are of no clinical significance unless associated with stones. Isolated location on Hartmann's pouch, body or neck have been explained on disordered embryogenesis but diffuse location all over the gall bladder is difficult to explain. We report a patient in whom multiple gall bladder diverticula were associated with a stone in the common bile duct.     

A novel in vitro bladder pelvic nerve afferent model in the rat

OBJECTIVE: To develop an in vitro model to allow electrophysiological recordings from pelvic nerve afferents of the urinary bladder in the rat and to ascertain the stability and reproducibility of the model with time. MATERIALS AND METHODS: Six male Wistar rats (body weight approximately 100 g) were used in the study. The bladder (complete with accessory organs of prostate and seminal vesicles), urethra and penis, together with the attached pelvic nerve and L6/S1 nerve trunk, were removed intact and placed in a specially designed recording chamber containing oxygenated Krebs solution maintained at 30 degrees C. The bladder was catheterized urethrally and attached to a continuous-infusion pump and a pressure transducer. The L6/S1 nerve trunk was placed across a silicone-gel wall into a separate chamber containing liquid paraffin, in which multiunit recordings from pelvic nerve afferents originating from the bladder were made. The afferent nerve activities in response to repeated bladder distension with saline, at 0.04 mL/min for 8 min over 3 h, were compared using the paired t-test to assess the reproducibility of the model. Conduction velocity studies were also carried out to ascertain the proportion of C- and A delta-fibres in the multiunit recordings. RESULTS: Repeated bladder distension with saline over 3 h produced consistent and reproducible afferent nerve responses, signifying that the afferent nerves recorded in this study neither sensitize nor desensitize over time. This is an essential prerequisite when using this model to study the effects of pharmacological manipulation of the bladder on its afferent nerve response. Conduction velocity studies showed that approximately 30% of the afferent fibres recorded from were C-fibres with the remaining being A delta-fibres. CONCLUSIONS: An in vitro bladder pelvic nerve afferent model for the rat was developed successfully; it is stable and produces reproducible results with repeated bladder distension over at least 3 h.     

Bladder compliance in patients with benign prostatic hyperplasia

Factors influencing bladder compliance were examined in 116 patients with benign prostatic hyperplasia (BPH), by evaluating patients' histories, response of isolated bladder strips to acetylcholine, and the effect of prostatic urethral anesthesia. Patients' age, frequency of micturition, and duration of voiding difficulty were not correlated with bladder compliance. Bladder compliance was significantly low in patients within 30 days after urinary retention, as compared with bladder compliance in patients without an episode of retention. More than 30 days after retention, however, there was a tendency toward increased bladder compliance. Restricted to patients without an episode of retention, bladder compliance in the overactive detrusor group was found to be significantly lower than in the normal group. The responses to acetylcholine of bladder strips were compared between patients with low and normal-compliance bladders. The dose-response curve of patients with low-compliance bladders did not differ from that of those with normal compliance bladders, even when patients with an episode of retention were excluded. After prostatic urethral anesthesia, a significant increase of bladder compliance was observed in patients with an overactive detrusor, while the increase was not significant in patients with a normal detrusor. Our results strongly suggest that easy irritability of the anatomically altered prostatic urethra, as well as bladder over-distension caused by urinary retention, are important factors affecting bladder compliance in BPH patients.