Chloride absorption in patients with a continent ileocaecal reservoir (Mainz pouch I)

OBJECTIVE

To determine the rate of radioactive chloride absorption at various times after surgery in patients with a continent ileocaecal reservoir (Mainz pouch I).

PATIENTS AND METHODS

The study was conducted on 20 patients (15 males and five females, mean age 47 years, range 15-72) who had undergone a Mainz pouch I urinary diversion. The patients were divided into three groups according to the duration of the post-operative follow-up, i.e. group 1 for < 6 months (n = 7), group 2 for 6-12 months (n = 8) and group 3 for > 12 months (n = 5). Radioactive 38Cl (20 MBq) was instilled into the pouch and the radioactivity determined in the blood, pouch and body interstitium every 20 min for 3 h. Samples for arterial blood-gas and acid-base profiles were obtained before and after instillation.

RESULTS

In patients in group 1, 93% of the instilled chloride was absorbed into the circulation, while 51% was absorbed by patients in group 3. The acid-base profile showed no significant changes before and after chloride instillation.

CONCLUSION

The absorption of chloride declines markedly with time after surgery in patients with a Mainz pouch I ileocaecal reservoir.

Urinary diversion in children and young adults using the Mainz Pouch I technique

OBJECTIVES

To determine the late complications and consequences for renal function, vitamin and acid-base metabolism after application of the Mainz Pouch I (MZP-I) technique in children and young adults.

PATIENTS AND METHODS

To November 1994, the MZP-I procedure was carried out in 463 patients at our institution, 91 of whom were children and adolescents (< or = 20 years old) using bladder augmentation in 21 and a continent cutaneous stoma in 70. A minimum follow-up of 1 year was possible in 87 patients or 163 renal units (RUs) with a mean of 5.5 years (range 1-10.5).

RESULTS

At the last examination, 23 of 55 (42%) preoperatively dilated RUs had improved. 131 of the 163 RUs (80%) were stable and nine RUs (5.5%) showed a slight clinical asymptomatic increase in the upper tract dilatation. Through an extraperitoneal flank incision, 11% of the RUs which developed stenosis at the ureterocolic anastomosis were successfully reimplanted (16% in patients with neurogenic disorders, 17% with pre-operative irradiation and 5% in the remaining patients). Two of 32 patients with an intussuscepted and invaginated ileal nipple required re-operation due to incontinence, but none of the patients with an appendiceal stoma were incontinent. Open revision of a stomal stenosis was performed in three and endoscopic treatment in nine patients. In 54 patients, the levels of vitamins A, B1, B2, B6, E, folic and bile acid were within normal ranges. There was no significant decrease in vitamin B12 levels after operation. In none of the patients with normal pre-operative creatinine values had the levels increased and none developed severe acidosis or bowel neoplasm.

CONCLUSION

The MZP-I is recommended as a technique for bladder augmentation or continent urinary diversion in children and young adults, with an acceptable complication rate which offers long-term protection of the upper urinary tract.

Vitamin metabolism in patients with a Mainz pouch I: long-term followup

PURPOSE

We assessed whether creation of the Mainz pouch I, which requires 24 to 36 cm. of terminal ileum and 12 cm. of ascending colon including the ileocecal valve, leads to metabolic disturbances.

MATERIALS AND METHODS

In 137 patients the levels of vitamins A, B1, B2, B6, B12, D and E, folic and bile acids, ammonia, and intracorpuscular vitamin B12 and folic acid were evaluated and a red blood count was performed. Patients were divided into children and adults, and into 3 groups according to number of years after surgery (2 or less, more than 2 to 4 and more than 4).

RESULTS

In all patients the levels of vitamins A, B1, B2, B6, D and E, folic and bile acids, and ammonia as well as red blood count were within normal ranges. In the 51 children there was no significant decrease in vitamin B12 postoperatively. In the 86 adults mean serum vitamin B12 plus or minus standard deviation decreased significantly from 402 +/- 182 ng./l. during the first 2 years postoperatively to 292 +/- 204 ng./l. after year 4 (normal 240 to 1,100). There was no significant decrease in intracorpuscular vitamin B12 during this period.

CONCLUSIONS

In addition to regular examinations, the determination of vitamin B12 levels 4 years after Mainz pouch diversion is mandatory. It remains unclear whether substitution is necessary. However, substitution is easy to achieve and even less expensive than the regular determination of vitamin B12.

Quality of life and health in patients with urinary diversion: a comparison of incontinent versus continent urinary diversion

OBJECTIVE

To compare the quality of life and health in patients with incontinent and continent urinary diversions, in correlation with the initial diagnosis, diversion-related symptoms, psychological status and employment status.

MATERIALS AND METHODS

81 patients (64% male and 36% female) with a mean age of 55 years (18-65 years) were included in this retrospective study. A total of 27 had an incontinent urinary diversion (group A) and 54 a continent diversion (group B). The initial diagnosis was malignant tumor in 75% (n = 61) and nontumor disease in 25% (n = 20). A structured interview and psychometric instrument assessment of the quality of life as well as somatic and psychological symptoms were carried out and analyzed.

RESULTS

Patients with nontumor disease, a continent reservoir and employment tended to have the highest level of quality of life. The higher the number and severity of psychological symptoms, such as depression and anxiety, the lower the level of global satisfaction with life, health and urinary diversion, and vice versa. No difference was seen between groups A and B concerning diversion-related symptoms, global satisfaction with life and health and sociodemographic data.

CONCLUSIONS

The decision for a continent versus an incontinent urinary diversion must consider not only the medical factors of each individual patient, but also the initial diagnosis, psychological condition and employment status.

Treatment of patients with bladder exstrophy or incontinent epispadias. A long-term follow-up

OBJECTIVE

To determine the late outcome concerning urinary continence, late complications, sexuality, and fertility in patients with the exstrophy-epispadias complex.

METHODS

Until July 1994, 115 patients underwent surgical treatment at our institution. The mean follow-up period in 102 patients is 16.7 years. Urinary diversion was performed in 88 patients, a modified Young-Dees procedure in 8, a sling plasty in 3, and genital reconstruction alone in 3 patients.

RESULTS

The present continence rates are 96% for rectal reservoirs, 97% for Mainz pouch 1, and 67% for the modified Young-Dees procedure. The upper tracts have remained stable, and no bowel neoplasms have developed. 16 of 17 women > or = 18 years of age are satisfied with the cosmetic result after genital reconstruction. All adults engage in sexual intercourse; 5 women have delivered 7 children by cesarean section. 30 of 32 male adults are satisfied with the cosmetic result of the reconstructed external genitalia. Penile deviation was present in 11, distressing in 2 patients. After genital reconstruction 9 developed epididymitis, necessitating 2 orchiectomies and 3 vasectomies. No patient with reconstruction of the external genitalia can ejaculate normally or has fathered children, whereas the ejaculation was normal in 3 who did not undergo genital reconstruction. Furthermore, 2 of the 5 have fathered 4 children.

CONCLUSIONS

Rectal reservoirs represent our urinary diversion of choice. After failed reconstruction/insufficient anal sphincter, a Mainz pouch I is constructed. The cosmetic results achieved by genital reconstruction are satisfactory. In women, antefixation of the uterus should be performed before or together with an introitus plasty to prevent uterine prolapse. In men, however, surgery is performed at the expense of fertility.

Automated image analysis DNA cytometry to predict the pathological stage in clinical stage I nonseminomatous testicular germ cell tumors

OBJECTIVE

Automated image analysis DNA cytometry was used to predict the pathological stage in clinical stage I nonseminomatous testicular germ cell tumor patients.

METHODS

Orchiectomy specimens of 74 patients (41 pathological stage I, 33 pathological stage II) were analyzed by modular image analysis computer, and several mathematical indices from the DNA histogram were calculated.

RESULTS

The 5c-exceeding rate (rate of hyperpentaploid nuclei) was found to be significantly higher in patients with pathological stage II disease as compared with patients without metastases (p = 0.0174). Tumor tissue from lymph node metastases showed even higher amounts of hyperpentaploid nuclei (p < 0.0005). In this study, all patients with a 5c-exceeding rate above 3.1% had metastatic disease.

CONCLUSIONS

Single-cell cytophotometry was able to show significant differences in 5c-exceeding rates between patients with and without tumor metastases. Because of high standard deviations, however, it was not possible to use this parameter for correct staging in all patients.

Management of bladder exstrophy and incontinent epispadias: 25 years of experience with urinary diversion

OBJECTIVES

Achieving complete urinary continence with preservation of the upper urinary tract in the exstrophy-epispadias complex must be the primary aim. To determine the optimal surgical approach, we reviewed the records of patients treated at our institution.

METHODS

During the last 26 years, 95 patients with bladder exstrophy and 20 with incontinent epispadias were operated upon at our department. For this retrospective study a total of 102 patients could be interviewed. Mean followup after the first operation was 16.7 years. Of the 102 patients, in 43 primary treatment was performed at our institution (urinary diversion n = 39, modified Young Dees n = l, sling plasty n = 3). A further 59 patients were referred to our institution for secondary treatment, 34 of whom after primary bladder closure and/or bladder neck reconstruction (urinary diversion n = 27, modified Young Dees n = 7).

RESULTS AND CONCLUSION

Of the 8 patients with modified Young Dees, 5 required conversion to a Mainz Pouch I due to obstruction of the reconstructed bladder neck or incontinence. Continence rates are 96% for the rectal reservoirs, 97% for the Mainz Pouch I and 67% for the modified Young Dees procedure. Presently, none of the 102 patients has deterioration of the upper urinary tract or has renal insufficiency; none has developed severe metabolic complications or bowel neoplasms. The physical, social and psychological development of the patients treated at our institution appears to be comparable to that of the general population. All children over 6 years of age attend elementary school, most of the adults are, well-educated, only three are unemployed and one lives in a therapeutic center as a result of multiple physical problems. Rectal reservoirs are the urinary diversion of choice at our institution in patients with bladder exstrophy or incontinent epispadias. When the upper urinary tract has deteriorated, a colon conduit is created with the option of conversion to a continent form of diversion as soon as renal and ureteral functions have recovered. In patients with failed urinary tract reconstruction/insufficient anal sphincter function, we prefer the Mainz Pouch 1.

Colonic conduit in children: protection of the upper urinary tract 16 years later?

PURPOSE

Complication rates of up to 86.6% have been reported after creation of an ileal conduit. In contrast to others, we construct an antirefluxing isoperistaltic colonic for incontinent diversion in children.

MATERIALS AND METHODS

Between 1968 and 1989 a colonic conduit was created in 105 patients up to age 20 years for neurogenic bladder (76), bladder exstrophy (16) and other reasons (13). Long-term followup (minimum 5 years, mean 16.3 years, range 5 to 26) was possible in 84 patients (159 renal units).

RESULTS

Early and late stenosis at the ureterocolic anastomosis, and stomal stenosis occurred in 7.6 and 15.5% of the cases, respectively. Renal calculi developed in 8.2% of the renal units. Eight kidneys without function after recurrent pyelonephritis, calculi or stenosis at the ureterocolic anastomosis were removed during followup. Compared to preoperative status 3 of the remaining 151 renal units had increased dilatation of the upper urinary tract at the last followup. A total of 31 patients had complications during followup and 18 underwent conversion to continent urinary diversion.

CONCLUSIONS

When incontinent urinary diversion is necessary in children, a colonic conduit with the option of continent conversion should be created before deterioration of the upper urinary tract.

Social integration, sexual behavior and fertility in patients with bladder exstrophy--a long-term follow up

After primary bladder closure or urinary diversion, other factors apart from the reconstruction itself gain importance for individuals with the exstrophy-epispadias complex: social integration and, after reaching puberty, sexuality and fertility. Between 1968 and July 1994 115 patients with bladder exstrophy or incontinent epispadias underwent surgery at our institution. A total of 104 patients could be followed, 2 of whom died in the meantime. Of the remaining 102 patients 48 attend school, 4 are in college, 40 have completed or are currently undergoing vocational training, 3 are unemployed, 1 lives in a therapeutic centre and 6 are younger than 6 years of age. A total of 95% of the patients with continent urinary diversion are continent day and night, whereas only three of five patients with a sling plasty (incontinent epispadias) or with primary bladder closure followed by a Young-Dees procedure are continent. None of the patients showed deterioration or renal function. In 25 females the external genitalia were reconstructed. Fixation of the uterus was done in 13 to correct or prevent uterine prolapse. Of the 17 women older than 18 years of age with genital reconstruction, 16 are satisfied with the cosmetic result. All adults engage in sexual intercourse. Five women have delivered seven children by Caesarean section. Of the 35 male adults 32 underwent reconstruction of the external genitalia and 34 males achieve erection. One developed necrosis of the penis early in life following primary bladder closure performed at an outside hospital. Penile deviation was present in 11 of the 32 patients with genital reconstruction, which is distressing in only 2. Thirty patients are satisfied with the cosmetic result. After genital reconstruction 9 males developed epididymitis, necessitating two orchiectomies and three vasectomies. No patients with reconstruction of the external genitalia can ejaculate normally or has fathered children, whereas ejaculation was normal in the three men who did not undergo genital reconstruction and in two patients prior to post-pubertal reconstruction. Furthermore, two of these three men have fathered four children.

CONCLUSION

Education, occupation and social development of patients with urinary diversion are uneventful. The cosmetic results achieved by genital reconstruction are satisfactory. In female patients, antefixation of the uterus should be performed before or together with an introitusplasty to prevent uterine prolapse. In male patients, however, surgery is performed at the expense of fertility. Detailed discussions with the patients and their patients should include not only the question of primary bladder closure versus urinary diversion, but also the pros and cons of correction of the external and-in females-the internal genitalia.

Appendiceal continence mechanisms in continent urinary diversion

The creation of a safe, reliable, and easy-to-perform continence mechanism remains one of the most important problems during continent urinary diversion. The advent of the use of the appendix as an efferent segment brought through the umbilicus has greatly facilitated surgical procedures with very favorable results. Our experience with the insitu appendix as an efferent segment during continent cutaneous urinary diversion using the Mainz-pouch I technique over the past 6 years revealed a markedly decreased complication rate of 3.2% as compared with 7.2% in patients who received an ileocecal intussusception nipple. The routine use of the appendix as a continence mechanism during continent urinary diversion has proved to be a most valuable addition to our surgical armentarium.

Continent diversion with the Mainz pouch

From 1983 until July 1994, 561 patients in 2 urology departments (Mainz and Wuppertal) underwent a Mainz pouch 1 procedure. The Mainz pouch 1 was used for bladder augmentation in 60 patients, for orthotopic bladder substitution in 61 patients, and for continent cutaneous urinary diversion in 440 patients. In the group of continent cutaneous urinary diversion, the continence mechanism applied was an ileal intussusception nipple in 270 patients, an appendix stoma in 146 patients, a submucosal seromuscular bowel-flap tube in 14 patients, and a submucosal full-thickness bowel-flap tube in 10 patients. Indications for urinary diversion were bladder cancer in 339 patients, anatomical or functional loss of bladder capacity in 179 patients, and other primary or secondary malignancies of the bladder or true pelvis in 43 patients. After a mean follow-up period of 57 months (range, 3-127 months), early and late complications were encountered in 12% and 37% of the patients, respectively. In the bladder-augmentation group, 93% of the patients are completely continent day and night. All but three patients, who empty their reservoir by intermittent self-catheterization (CIC), void spontaneously by abdominal straining. In the orthotopic bladder-substitution group, 95% of the patients are continent during the daytime. To prevent urinary leakage, 13% have to empty their reservoirs regularly at 4-h intervals and 13% have to perform CIC to avoid residual urine. Among the patients treated with continent cutaneous urinary diversion, stoma failure occurred in 11%, stoma stenosis was encountered in 13% and required open revision in 2%, endoscopical incision in 10%, and conservative treatment (dilation) in 1% of cases.

The sigma rectum pouch (Mainz pouch II)

A low-pressure reservoir for urine is created by antimesenteric splitting and side-to-side anastomosis of the rectosigmoid, the expectation being to obtain better continence rates and better protection of the upper tract than are achievable by ureterosigmoidostomy. Between 1990 and August 1993 the procedure was performed in 73 patients (59 adults and 14 children) whose mean age was 43.5 years. The indications were malignancy (n = 55), bladder exstrophy/epispadias (n = 14), trauma (n = 3), and sinus urogenitalis (n = 1). Of the 73 patients, 69 were followed for a mean period of 127 (range, 1-34) months. In all, 5 early complications were encountered (6.8%). In addition, 8 late complications occurred (10.9%), stenosis at the ureteral implantation site being the most common one. Daytime continence was 94.5% and night-time continence, 98.6%. The sigma rectum pouch achieves excellent continence rates. Despite implantation of the ureters into a low-pressure reservoir, stenosis at the site of ureteral implantation occurred in 6.8% of the patients, demonstrating the profund vulnerability of ureterointestinal anastomosis.

[Properties and acceptance of Melolin wound dressing in postoperative management of male urethral reconstruction]

In a prospective study we examined the quality and acceptance of the non-adhesive wound dressing Melolin during postoperative treatment following urethral reconstruction in 30 male patients. The wound dressing was cut individually for each patient and sterile Bepanthen ointment was applied to it. We fixed the dressing with a cohesive elastic bandage (Easifix Cohesive) and three cutaneous stiches and left it in place for 9 days. Both acceptance and absorbance of this bandage were good. Complete removal of the wound dressing was possible with no problems, although a camomile-water bath was necessary in two cases. No wound infections were observed. As functional and cosmetic results are so good, we now use this wound dressing routinely.

Urinary diversion in bladder exstrophy and incontinent epispadias: 25 years of experience

PURPOSE

To determine the optimal surgical approach in achieving complete urinary continence with preservation of the upper urinary tract in the exstrophy-epispadias complex we reviewed the records of patients treated at our institution.

MATERIALS AND METHODS

From 1968 to July 1994, 115 patients with bladder exstrophy/incontinent epispadias were treated of whom followup was available for 104 and 2 died of causes unrelated to urinary diversion. Mean followup is 16.7 years. In 43 of the 102 patients surgery was primarily performed at our institution (urinary diversion in 39, a modified Young-Dees procedure in 1 and sling plasty in 3). In another 59 patients urinary diversion was done secondarily after therapy elsewhere (bladder closure/bladder neck reconstruction in 34 and failed urinary diversion with incontinence in 22). Urinary diversion was performed in 49 patients, a Young-Dees procedure in 7 and genital reconstruction alone in 3.

RESULTS

The present continence rates are 96% for the rectal reservoir, 97% for the Mainz pouch I and 67% for the modified Young-Dees augmentation. Upper tracts have remained stable and no bowel neoplasms have developed.

CONCLUSIONS

Rectal reservoirs represent our urinary diversion of choice. After failed reconstruction/insufficient anal sphincter a Mainz pouch I is constructed and when the upper tract has deteriorated a colon conduit is created.

Operative reconstruction of the external and internal genitalia in female patients with bladder exstrophy or incontinent epispadias

PURPOSE

Urologists and gynecologists rarely encounter questions on cohabitation and pregnancy in female patients with bladder exstrophy or incontinent epispadias.

MATERIALS AND METHODS

Until 1994, 41 female patients underwent surgery at our institution (vaginal cutback or vaginoplasty in 23, correction of the external genitalia in 25 and uterus fixation to correct or prevent prolapse in 13).

RESULTS

Followup was available in 37 patients (mean 16.8 years, with followup of 18 years or longer in 19). Of the patients 94% are satisfied with the cosmetic results. All adults engage in sexual intercourse, 4 delivered 6 children by cesarean section and 5 presently desire children.

CONCLUSIONS

Fertility in patients with bladder exstrophy or incontinent epispadias is normal, and pregnancy is possible. Patients and parents should be well informed. Besides urinary tract reconstruction, correction of the external and internal genitalia should be discussed in detail.

Surgery in rhabdomyosarcoma of the bladder, prostate and vagina

The treatment of bladder and prostate rhabdomyosarcoma (RMS) is highly controversial. Aside from chemotherapy, treatment modalities include conservative surgery, radical surgery, and pre-, intra-, or postoperative irradiation. Between 1968 and 1993, 78 children with RMS were treated at our institution. In all, 22 tumors were located in the urogenital tract (bladder/prostate, 13; paratesticular, 5; vaginal, 2; others, 2). Altogether, 6 patients had stage II disease; 7, stage III disease; and 2, stage IV disease. All 15 patients with RMS of the bladder, prostate, or vagina received chemotherapy, and 4 had additional radiotherapy. Surgery was also done in 10 patients; parents refused an operation in 3 cases. In all, 3 patients in an advanced tumor stage died of their disease. All other children currently show no evidence of disease (mean follow-up, 6 years; range, from 2 months to 18 years). After chemotherapy, radical operative intervention with multiple biopsies (encircling the tumor)--in contrast to local tumor excision or partial resection--permits complete tumor resection followed by excellent long-term results. Following radiotherapy, often a consequence of organ-sparing therapy, many complications ensued (60%); therefore, irradiation should be restricted to highly selected cases.

[The continent ileocecal pouch. The Mainz pouch I]

Since 1993 to July 1994, 374 patients underwent a Mainz Pouch procedure in their hospital. The follow up is between 4.2 +/- 2.6 years. The authors used this technique as well for bladder augmentation, bladder substitution as continent diversion. If possible, the appendix will be used for creating the continence system.

[The rectosigmoid pouch. The Mainz pouch II. Apropos of 73 cases]

The Mainz Pouch II, a low pressure rectosigmoid réservoir for urine is created without any bowel anastomosis. Antimesenteric opening of the intestine at the rectosigmoid junction and subsequent wide-to-side anastomosis are performed. Without the risque of damaging the mesentery blood supply, the pouch is fixed at the area of the pomontory or the psoas muscle to avoid the kinking of the ureteres and consecutive dilatation of the upper tract.

The fate of the adult exstrophy patient

Between 1968 and 1993, 101 patients with bladder exstrophy or incontinent epispadias underwent surgery at our hospital. The standard procedure was ureterosigmoidostomy and additional genital reconstruction. Of the 56 patients who have reached adulthood 45 could be interviewed regarding social integration, sexuality and fertility. All patients have a functioning urinary diversion. Of the 45 patients questioned 41 have completed vocational training or are currently in training, 3 are unemployed and 1 lives at a therapeutic center. Among the patients 29 are married or have a steady partner. All women engage in sexual intercourse and 2 have delivered 3 children by cesarean section. All men achieve erection. Of the 28 men who underwent reconstruction of the external genitalia 11 have a penile deviation, which is distressing in only 2. Only 3 of the men are dissatisfied with the cosmetic result and 33% had epididymitis, necessitating 2 orchiectomies and 3 vasectomies. No patient with reconstruction of the external genitalia can ejaculate normally or has fathered children, whereas all 5 who did not undergo genital reconstruction had normal ejaculation and 2 have fathered children. Male patients with genital reconstruction and closure of the urethra have a high risk of infertility. Our patients demonstrate that the cosmetic results after genital reconstruction are satisfactory. However, in male patients, surgery is performed at the expense of fertility. Because this corrective procedure is usually performed during childhood, the parents must be informed of these consequences before surgical correction.

Ileocecal valve reconstruction during continent urinary diversion

During construction of an ileocecal reservoir, such as the Mainz or Indiana pouch, the ileocecal valve is lost. Subsequently, the intestinal transit time is shortened and malabsorption as well as diarrhea may result. Patients having undergone previous bowel resection as well as children with myelomeningocele who often already have frequent defecations will be heavily affected by the loss of the ileocecal valve. We have functionally reconstructed the ileocecal valve by embedding ileum into the ascending colon via a submucosal tunnel in analogy to the technique used when creating the continence mechanism during the Mainz pouch procedure using the appendix. Experimental results in 15 dogs demonstrated that the surgically reconstructed valve genuinely mimics the physiological function of the authentic valve and confirmed a marked transit time prolongation without evidence of obstruction. Our first clinical experience in 12 patients using this operative technique is promising. Equally, the morphological appearance of the newly created valve closely resembles the genuine ileocecal valve during barium enema as well as endoscopic investigations.

[Hydatid cyst of the interventricular septum. Apropos of a case]

A cardiac tumour of the interventricular septum was detected in a young woman presenting with an ejectional systolic murmur. Surgical ablation was carried out before a precise diagnosis was made. Histopathological analysis of the surgical specimen confirmed a hydatid cyst. The main complication was complete atrioventricular block. This case underlines the difficulty of making the diagnosis of intracardiac hydatid disease in a non-specific context, because of the long period of clinical latency, despite the considerable aid of echocardiography and other medical imaging techniques (CT scan and magnetic resonance imaging.

The Mainz pouch II

The Mainz pouch II procedure has proved to be a substantial modification of the classical technique of ureterosigmoidostomy at many institutions. To date we have used this procedure in 72 patients, including 15 children. Detubularization causes a low pressure and eliminates high-pressure contractions. Without the risk of compromising the blood supply the pouch is fixed at the promontory which reduces the risk of ureteral kinking and upper urinary tract dilatation as it is sometimes observed after ureterosigmoidostomy. The technique is not only indicated in cases of failed ureterosigmoidostomy but also for primary urinary diversion. Of the 72 patients operated, all are evaluable with a follow-up of 1-31 months. All patients are continent during the daytime with a mean emptying frequency of 5. All but one elderly woman are dry at night with a mean frequency of 1. The described urodynamic/rectodynamic evaluation enables a reliable prediction of postoperative continence. With the reservoir full the basal pressure was 24 cm H2O and the highest peak pressure recorded was 35 cm H2O.

Sigma-rectum pouch (Mainz pouch II)

A substantial modification of the classic technique of ureterosigmoidostomy is introduced in this article. To date, this procedure has been used in 47 patients. This article reviews the surgical technique of the antemesenterial splitting of the intestine at the recto-sigmoid junction which creates a pouch by subsequent side-to-side anastomosis.

The Mainz pouch II (sigma rectum pouch)

A low pressure rectosigmoid reservoir for urine is created obviating the need for colostomy, augmentation or extensive bowel surgery. Antimesenteric splitting of the intestine at the rectosigmoid junction and subsequent side-to-side anastomosis are performed. Urodynamic data demonstrate that the detubularization is effective in rendering high pressure bowel contractions ineffective. Without the risk of damaging the mesentery the pouch is fixed at the promontory, which lessens the risk of ureteral kinking and upper urinary tract dilatation. The technique is indicated not only in cases of failed ureterosigmoidostomy but also for primary urinary diversion. All 47 patients who underwent the operation were evaluable with a followup of 1 to 20 months (mean 10 months). All patients are continent during the daytime with a mean emptying frequency of 5 times. All but 1 elderly woman are dry at night with a mean frequency of 1 episode. With the reservoir full the basal pressure was 24 cm. water and the highest peak pressure recorded was 35 cm. water. The low pressure improves continence, protects the upper urinary tract and even allows dilated ureters to be implanted.

Osseous fixation of a penile prosthesis after transsexual phalloplasty: a case report

We report on a patient who had undergone female-to-male transsexual surgery and subsequent phalloplasty by means of a free latissimus dorsi muscle graft with pudendal nerve coaptation elsewhere 10 years ago. The surgical strategy for implantation and osseous fixation of a penile prosthesis is described. We discuss whether the primary implantation of a penile prosthesis during 1-stage surgical phalloplasty is more advantageous in comparison with the currently favored secondary implantation. Phalloplasty should be represented by a 1-stage surgical procedure encompassing the creation of a neourethra, restoration of tactile and possibly erogenous sensibility, and implantation of a penile prosthesis. The result should have aesthetic value and be pleasing to the patient.

[The "Mainz pouch" technique (bladder augmentation with ileum and cecum) for bladder augmentation, bladder substitution, and continent urinary diversion]

Back in 1983 we created a continent urinary reservoir, called the MAINZ pouch, using 10 to 15 cm. of cecum as well as two terminal ileal segments of equal length. Following detubularization, the posterior wall of the pouch is established by anastomosis of the ascending colon with the terminal ileal loop starting at the inferior aspect. The latter is then anastomosed with the next proximal ileal segment. The ureters are implanted in an antirefluxive manner in the open end technique through a submucosal tunnel of 4 to 5 cm length. For bladder augmentation the pouch is anastomosed to the bladder remnant. For bladder substitution a buttonhole incision at the most inferior aspect of the cecal pole is placed or the appendix is used for end-to-end anastomosis to the membranous urethra. For continent diversion an additional 7 to 12 cm of ileum are isolated in order to create an ileal intussuscepted valve. Alternatively the appendix can be used. Continence is achieved by submucosal embedding of the appendix into the cecal pole. A total of 346 patients underwent the MAINZ pouch procedure in Mainz and Wuppertal; 56 for bladder augmentation, 49 for bladder substitution and 241 for continent urinary diversion. We encountered early complications in 29 of the 346 patients (8.38%). Late complications were observed in 72 patients (20.8%). The major complications we encountered were stone formation inside the pouch in 19 patients and stomal stenosis in 21. 54 of the 56 patients with a bladder augmentation are completely continent (mean follow-up: 50 months, range: 10 to 83 months). All of the 49 patients who received a bladder substitution after radical cystectomy are continent during daytime. Three of these patients who do not empty their bladder at regular four hour intervals have leakage during the night (follow-up: 23 to 69 months). The revision rate due to nipple gliding and subsequent incontinence could be greatly reduced by the use of staples for fixation of the ileal nipple and the use of the appendix. For correction of the most frequently occurring complications standardized techniques have been developed.

Seven years experience with the Mainz pouch procedure

In 1983 we created a form of continent urinary diversion termed the Mainz pouch procedure utilizing cecum and ileum. For creation of the reservoir 10 to 15 cm of cecum and ascending colon as well as two terminal ileal segments of equal length are isolated and detubularized. The posterior wall of the pouch is completed by anastomosis of the ascending colon with the terminal ileal loop starting at the inferior aspect. The latter is then anastomosed with the next proximal ileal segment. The ureters are implanted in an antirefluxive manner in the open end technique through a submucosal tunnel of 4 to 5 cm of length. For bladder augmentation the pouch is anastomosed to the bladder remnant. For bladder substitution a buttonhole incision at the most inferior aspect of the cecal pole or the appendix is used for end-end anastomosis to the membrancus urethra. For continent diversion and additional 8 to 12 of ileum are isolated in order to create an ileal intussuscepted valve. Alternatively the appendix can be used. Continence is achieved by submucosal embedding of the appendix into the cecal pole. A total of 281 patients underwent the Mainz pouch procedure, 54 for bladder augmentation, 7 for bladder replacement and 200 for continent urinary diversion. We encountered early complications in 15 of the 281 patients (5.3%). Late complications were observed in 63 patients (22.4%). The major complications we encountered were stone formation inside the pouch in 17 patients and stomal stenosis in 19. Fifty-two of the 54 patients with a bladder augmentation are completely continent (mean follow-up: 50 months, range: 10 to 83 months). All of the 27 patients who received a bladder substitution after radical cystectomy are continent during daytime. Three of these patients who do not empty their bladder at regular four hour intervals have leakage during the night (follow-up: 23 to 69 months). The revision rate due to nipple gliding and subsequent incontinence could be greatly reduced by the use of staples for fixation of the ileal nipple and the use of the appendix. For correction of the most frequently occurring complications standardized techniques have been developed.

Pediatric urinary diversion: review and own experience

New insights into the diseases of childhood, profound improvements and new developments in surgical techniques as well as the knowledge gained from long-term follow-up have altered the strategies and indications for urinary diversion in childhood. Continent urinary diversion is generally the method of choice. We are able to construct high capacity, low pressure reservoirs to protect the upper urinary tract and achieve continence. Nowadays, there is hardly any indication for permanent cutaneous urinary diversion. Temporary and intermediate cutaneous diversion are used only when serious conditions such as renal function deterioration occur. The possibility to convert any incontinent form of urinary diversion into a continent form changed the status of intermediate diversion. The indications for urinary diversion, the procedures available, the operative technique, a literature review, our own experience, contemporary strategies and controversies are described and discussed.

The appendix as a continence mechanism

Although we have progressed very well in creating large capacity, low pressure reservoirs, the construction of a simple and reliable continent outlet still remains a problem. The appendix vermiformis serves well as a continence mechanism for either the bladder or intestinal reservoirs for urine. The different surgical techniques described in the literature are reviewed and discussed in this context. Moreover, we report on our clinical and experimental results of using the appendix during the Mainz pouch procedure for continent urinary diversion.

Pyelotransverse pyelocolostomy: an alternative method for high urinary diversion in patients with extended bilateral ureter damage

After previous radiation due to pelvic malignoma or after multiple operations, the ileal conduit as well as sigmoid conduit are associated with an increased rate of complications. In these patients, the middle and distal ureter often cannot be considered for reimplantation due to fibrosis. High anastomosis to a bowel segment which is undamaged proves favorable. The transverse colon, conveniently situated in the cranial abdomen, is close enough to the kidneys for such a high anastomosis and is mostly spared from irradiation. In cases where severely damaged ureters forbid connection to a normal transverse conduit, we performed a pyelotransverse pyelocolostomy with high anastomosis of the bowel to both renal pelves or ureteropelvic junctions. 7 patients have been treated in this way and the follow-up of these patients ranges between 14 and 24 months. Postoperatively increased renal function was found in 6 renal units, stable function in 6 renal units, and only 1 patient showed a functional ureteropelvic stenosis. 4 months after the operation 1 patient died of sepsis caused by recurrent urinary tract infections due to recurrent stone disease as a consequence of immobilization in myelomeningocele. In patients with nearly total loss of ureters the pyelotransverse conduit is an effective surgical solution and may prove more comfortable to the patient than bilateral percutaneous nephrostomies.

Quasi-elastic light scattering of antigen-antibody complexes

Many biological properties of immune complexes (IC) depend upon their size. Quasi-elastic light scattering (QLS) was used to measure a mean equivalent hydrodynamic radius (Rh) and variance of the distribution of model IC composed of bovine serum albumin (BSA) as antigen (Ag) and combinations of two or three well-characterized monoclonal antibodies (MAb) which bound noncompetitively to unique epitopes on BSA. With the molar ratio (X) of each MAb to Ag fixed, Rh increased with concn. Rh was maximal at equivalence (X = 0.5) with two MAb and at slight MAb excess (X = 0.67) with three MAb. The largest Rh with two MAb was about 200 A, and Rh was uniformly different amongst the three combinations of two MAb IC. The largest hydrodynamic radius of individual complexes which formed with two MAb was estimated to be about 400 A; even larger individual complexes were formed with three MAb. Size changes following alteration of solution concns were also followed with QLS. Kinetics of two MAb IC association were too fast to observe; dissociation following large dilution (40-fold) required 5-10 min to attain a new steady state, much less at small dilution. With three MAb, Rh dropped sharply in 5 min and became steady after 1-2 hr. These results suggest that conventional chromatographic and ultracentrifugation techniques for studying IC size, involving large dilution and long measurement time, provide misleading results. Association of three MAb produced a rapid initial increase of Rh in several min, followed by diverse behavior which depended upon concn. From high to low concn, these included (1) exponential growth of Rh with time and appearance of visible macroscopic particles; (2) metastable states for several hr followed by slow growth to large size over several days, leading to formation of particles; and (3) rapid growth to steady state conditions with no visible particles. This heretofore unobserved equilibrium and kinetic behavior of model IC in solution may be reflected in the behavior of more complex, naturally occurring IC.

Solution studies of the quaternary structure and assembly of human von Willebrand factor

The reversible association of protomers of von Willebrand protein (vWF) was studied in order to analyze the forces and mechanism of vWF polymer assembly. At concentrations of vWF found in plasma (approximately 16 micrograms/mL), disulfide bond reduction with 50 mM 2-mercaptoethanol (2-ME) markedly reduced both vWF activity, as measured by ristocetin-dependent platelet agglutination, and average polymer size (Rh, the mean hydrodynamic radius) in solution, as determined by quasi-elastic light scattering (QLS) and by gel filtration chromatography. With increasing vWF concentration, activity and Rh increased despite reduction of interprotomer disulfide bonds. Changes in temperature after 2-ME treatment produced reversible changes in activity and Rh. Varying the total vWF concentration at any given temperature after 2-ME treatment changed Rh in a consistent and predictable fashion, so that estimates of the dissociation constant for vWF protomer-polymer equilibrium were obtained: Kd5 degrees C = 0.77 micrograms/mL, Kd25 degrees C = 2.4 micrograms/mL, and Kd37 degrees C = 7.7 micrograms/mL, where under the conditions of reduction presented here, the basic protomer of vWF is a dimer. Increasing ionic strength after 2-ME treatment with 1 M KCl did not change Rh, while approximately 100 microM sodium dodecyl sulfate (SDS) or approximately 300 microM sodium deoxycholate (DOC) reduced both Rh and activity compared with those of unreduced polymer. These data show that disulfide bonds are necessary to maintain vWF polymer size and activity at plasma concentrations but that noncovalent forces of association can maintain vWF polymer size and activity at higher concentrations. These forces of association may be important for polymer assembly during intracellular synthesis of vWF.