Malignancies in bladder augmentations and intestinal conduits

Long-term histopathological changes observed in rats subjected to augmentation cystoplasty

Possible development of proliferative lesions in bladders subjected to augmentation cystoplasty is a matter of concern for many clinicians. We have previously reported on the development of bladder papillomas in 5 of 15 rats approximately 18 months after gastrocystoplasty. We now report a followup study designed to investigate histopathological changes occurring in rat bladders approximately 2 years after augmentation cystoplasty using various gastrointestinal segments. Prepubescent Long-Evans female rats were randomly divided into 4 groups and underwent either gastrocystoplasty, ileocystoplasty, colocystoplasty or a sham operation (controls). Animals were sacrificed 14 to 27 months (average 21.5) postoperatively and bladders were examined histologically. Metaplastic and/or hyperplastic changes were observed in the gastrointestinal patches or surrounding urothelium in all bladders having undergone augmentation cystoplasty. Tumors occurred on or adjacent to the lumenal surface of the augmented segment in 4 of 10, 3 of 11 and 2 of 11 rats that underwent gastrocystoplasty, ileocystoplasty or colocystoplasty, respectively. None of the tumors was observed to invade blood vessels, lymphatics or the underlying muscle layers. However, histological features of malignancy characterized by varying degrees of cellular pleomorphism occurred in some tumors. Control rats (10) had only minor changes related to reapposition of tissues and remnants of suture. Possible etiologies and the potential significance of these augmentation cystoplasty related proliferative lesions are discussed.

Grafting of cultured uroepithelium and bladder mucosa into de-epithelialized segments of colon in rabbits

Urinary tract reconstruction using bowel can result in acid-base and electrolyte abnormalities. We tested the feasibility of grafting bladder mucosa and urothelial cells grown on a biodegradable polyglactin 910 scaffold onto de-epithelialized segments of bowel in the rabbit. A segment of de-epithelialized colon was either grafted with cultured urothelium on a collagen mesh scaffold (12 rabbits) or with free bladder mucosa (11 rabbits). In 10 rabbits that served as a control group another segment of bowel was isolated and de-epithelialized. No urothelial or bowel epithelial growth was present 4 weeks later in 10 of the isolated de-epithelialized colonic segments grafted with the cultured urothelium. In 2 segments a minute focus of epithelium staining positively for anticytokeratin antibodies AE1 and AE3 was seen but this could not be histologically differentiated as either urothelium or native colonic epithelium. All 7 surviving animals that underwent a bladder mucosal graft had viable urothelium at sacrifice 30 days postoperatively. In 2 of the 7 rabbits microscopic nests of colonic epithelium were also found underneath the urothelial layer. Of the 7 internal controls 6 had no evidence of bowel epithelial regrowth 4 weeks after de-epithelialization. This study demonstrated that a confluent layer of urothelial cells could be grown in culture using a scaffold of biodegradable mesh and rat tail collagen. We also showed that bladder mucosal grafts can be grown on de-epithelialized bowel segments. We were unable to graft successfully cultured urothelial cells onto a de-epithelialized bowel segment. Further improvement in understanding the role of the submucosal matrix in cell growth may lead to future success in covering large segments of de-epithelialized bowel with autologous urothelium.

Ureterocystoplasty: the 'bladder' augmentation of choice

OBJECTIVE

To reduce the complications of enterocystoplasty by augmenting the bladder with a megaureter.

PATIENTS AND METHODS

Ureterocystoplasty was performed in eight children aged 20 months-15 years. Three had impaired renal function and three were in established chronic polyuric renal failure.

RESULTS

The seven older children were dry by day with clean intermittent catheterization and the youngest, at the age of 3 1/2 years, had a dry interval of 2 h after catheterization. The three children with polyuric renal failure required nocturnal catheterization or were wet at night. The post-operative urodynamics showed a significant improvement in all cases with abolition of detrusor instability in seven patients and a reduction in end filling pressure. Bladder volume increased from a mean of 100 ml (range 45-215) to 311 ml (range 150-450) (P = 0.01). There was no deterioration in renal function.

CONCLUSION

The early results of ureterocystoplasty compare favourably with those of enterocystoplasty without the risks of long-term metabolic and neoplastic complications.

Indications for bladder augmentation in the exstrophy-epispadias complex

OBJECTIVE

To determine whether bladder augmentation has a role in avoiding urinary diversion in patients with exstrophy-epispadias complex (EEC), whether it can improve the lifestyle in patients who have previously undergone diversion or improve the result of any single surgical step in the staged functional reconstruction of the bladder in these patients.

PATIENTS AND METHODS

From 1970 to 1991, 85 patients were treated for EEC. Between 1981 and 1991, 12 bladder augmentations were performed in 11 patients (seven girls and four boys) with bladder exstrophy, male epispadias (one case) and cloacal exstrophy (one case).

RESULTS

No significant early surgical complications were reported. Follow-up ranged from 18 months to 11 years. Late complications included bowel obstruction in one patient, a partial left ureteric stenosis at the level of the anastomosis with the gastric patch wall in one patient and bladder lithiasis in five patients (sigmoidocystoplasty in one and ileocystoplasties in four). No metabolic problems, no bladder perforations or malignancies were observed. The results on continence were good and, with the one exception reported, the condition of the upper urinary tract following surgery was satisfactory in all patients.

CONCLUSION

Augmentation cystoplasty is of use in the treatment of patients with bladder exstrophy when staged functional reconstruction is unsuccessful. This technique greatly reduces the indications for urinary diversion and can be used in the surgical treatment of EEC. The only disadvantage is that clean intermittent catheterization must be performed, sometimes only temporarily, but patient acceptance is usually high.

Transverse colon conduit urinary diversion in patients treated with very high dose pelvic irradiation

OBJECTIVE

To study the results of transverse colon conduit urinary diversion in patients receiving very high dose pelvic irradiation (> or = 65 Gy).

PATIENTS AND METHODS

Records were reviewed for 30 such patients who underwent transverse colon conduit as a primary form of urinary diversion between January 1986 and June 1992. Most of the conduits were constructed using refluxing ureterocolic anastomoses with stents.

RESULTS

There was no operative mortality. Although the procedure was associated with a complication rate of 37% and a re-operation rate of 20%, there were no bowel or urinary anastomotic leaks. The operation could be safely performed on patients with renal failure, with 83% of such patients showing normal or improved serum creatinine levels post-operatively.

CONCLUSION

The advantages of transverse colon conduit urinary diversion are the use of non-irradiated bowel and ureters for diversion. We recommend it as a primary form of urinary diversion in these high risk cases.

Enterocistoplastica. Is it safe? Rischio a lungo termine di carcinogenesi sulla mucosa intestinale

The fact that adenocarcinoma occurs in patients with ureterosigmoidostomy is well-documented in literature and the increased risk of carcinoma has been estimated to be 200 to 550 times that of the general population. No case of adenocarcinoma in ileal orthotopic or ileal continent reservoirs has been reported, due to the long latency period for carcinogenesis (20-25 years). We report 2 cases of bladder neoplasms of intestinal origin in patients who underwent, in 1956 and 1963, bladder augmentations for bladder tuberculosis. Our cases suggest that a long-term surveillance of continent urinary diversions is mandatory, as well as a close check on urinary cytology.

Continent urinary reservoirs

With the increasing incidence of bladder cancer, many different operations have been devised to reconstruct the lower urinary tract in a continent fashion. The incontinent type of urinary reservoir (ileal conduit) has been a surgical preference for many years. However, the continent urinary reservoir (CUR), neobladder, and rectal bladder offer the capable and motivated patient an alternative to an incontinent permanent stoma. Nursing management of patients requiring diversional surgery requires continual updating of these specialized surgical procedures and unique aspects of care.

Salvaging the obstructed ureterosigmoidostomy using an ileal interposition technique

Ureterointestinal obstruction is a major complication of ureterosigmoidostomy and one that usually forces a flight to other forms of urinary diversion. Many patients, however, are reluctant to give up the life-style that ureterosigmoidostomy offers and prefer an alternative that permits retention of the basic features of the procedure. To satisfy these demands a technique has been developed in which an intussuscepted segment of small bowel is interposed between the colon and the ureters. This operation has allowed salvage of an obstructed ureterosigmoidostomy in 6 patients and has given such good results that it has been done as a primary procedure in 1. In addition to its use for the salvage of existing ureterosigmoidostomies, the operation permits primary ureterosigmoidostomy to be done in patients with dilated ureters, and it may even lessen the risk of colon cancer by separating the urothelium from the colonic mucosa.

Histopathological changes in Kock pouch

To investigate whether tumour recurrence or histological changes occur in the Kock pouch, periodic endoscopy with biopsy of the pouch was performed in 15 patients 6 to 66 months after radical cystectomy and urinary diversion for invasive bladder cancer. Endoscopy was undertaken 1 to 4 times in each patient (a total of 37 times in all patients). During endoscopy, random biopsies were taken from the pouch wall, and from the afferent and the efferent nipples. The histological changes were graded as: (1) villous atrophy (grade 0 to 3, 0: nearly normal; 1: shortening, villi/crypt of Lieberkuhn [length] between 1.5 and 4.0; 2: moderate flattening, villi/crypt < 1.5; and 3: almost complete disappearance of villi); (2) fibrosis; and (3) chronic inflammation (grade 0 to 3, based on the amount of fibrous tissue and inflammatory cell infiltration in the lamina propria, respectively). There was no dysplasia or malignant tumour in the Kock pouch in any of the 15 patients. The histology of the ileum changed in terms of villous atrophy, fibrosis and chronic inflammation in the lamina propria and thickening of the muscularis mucosa. The same grade of villous atrophy of the pouch wall, the afferent and the efferent nipples was only found in 3 patients. More fibrosis and less chronic inflammation in the lamina propria were found at the efferent nipple than at the afferent nipple or pouch wall in 8 patients and 5 patients, respectively. Thickening of the muscularis mucosa was found in 13 of 15 patients (86.7%). In conclusion, there was no dysplasia or recurrent tumour in the Kock pouch in patients who were followed for up to 66 months. Various grades of histological changes of the ileum in terms of villous atrophy, fibrosis and chronic inflammation of the lamina propria, and thickening of the muscularis mucosa were found in the pouch wall, and in the afferent and efferent nipples. More fibrosis and less chronic inflammation were commonly observed at the efferent nipple than at the afferent nipple or pouch wall. The degree of histological changes varied even among patients followed over the same period after operation. The time to progression of villous atrophy also varied. The histological changes in some patients were dissimilar even at the same site of the Kock pouch.

Histological and bacteriological findings in long-term ileocystoplasty and colocystoplasty in the rat

The long-term effects of bladder reconstruction using bowel were studied in rats. Bladder surgery consisted of cystotomy and closure, ileo- or colocystoplasty, or placement of a reverse serosal (Thal) patch of ileum. At least one-third of all groups received prophylactic cefaclor, postoperatively. Monthly urine cultures were obtained, and survivors were sacrificed at 1 year. Antimicrobial therapy markedly reduced the incidence of chronic colonization after cystoplasty. However, the majority of rats in the Thal patch group remained colonized because of acquired vesicoileal fistulae. Vesical stones were often present in this group and were also seen in 6 of 43 (14%) and 3 of 33 (9%) in the ileocystoplasty and colocystoplasty groups, respectively. Transitional cell papillomas and/or hyperplasia was seen at 20 of 42 (48%) uroileal and 20 of 31 (64%) urocolonic anastomoses (p = .15). Hyperplastic lesions could not be correlated with bacteriuria. Focal nonpapillary transitional cell carcinoma was seen once in the colocystoplasty group, and low grade papillary transitional cell tumors were noted once in each of the cystostomy and ileocystoplasty groups and twice in Thal patch rats with ileovesical fistulae. These findings suggest that the rat uroenteric anastomosis is susceptible to proliferative change which is rarely malignant in nature and occurs in the presence or absence of bacteriuria.

The valved S-shaped rectosigmoid pouch for continent urinary diversion

Continent urinary diversion to the valved S-shaped rectosigmoid pouch was performed in 9 female and 6 male patients 12 to 65 years old (mean age 51 years). The pouch was constructed by detubularization and S-shaped reconfiguration of 30 cm. of the intact rectum and sigmoid colon. The ureters were reimplanted into the pouch using antireflux techniques. Reflux of urine from the pouch to the proximal colon was prevented by fashioning an intussusception valve. The construction was protected by a transverse colostomy for 6 to 8 weeks. With a followup of 3 to 24 months (mean 11 months), all patients are continent during the day and also at night with evacuation intervals of 3 to 6 hours. There have been no cases of symptomatic urinary tract infection. Only 1 patient had mild hyperchloremic acidosis. No patient complained of abdominal distention or constipation. Contrast study via the anus (radiography of the pouch) showed that the intussusception valve was competent in all but 1 patient in whom reflux to the proximal colon was noted due to sliding of the nipple valve, which was revised successfully. Urodynamic studies (cystometry of the pouch) showed a capacity of 400 to 900 ml. (mean 600) with an intraluminal pressure of 22 cm. water (range 10 to 34) at maximal filling. The valved S-shaped rectosigmoid pouch is a faster and simpler surgical procedure compared with the modified rectal bladder (valved rectum augmented with ileum). It also results in a smooth postoperative course, since an intestinal anastomosis proximal to the colostomy is avoided.

Laparoscopic seromyotomy (auto-augmentation) for non-neurogenic neurogenic bladder in a child: initial case report

An eight-year-old boy with lifelong urinary incontinence secondary to non-neurogenic neurogenic bladder underwent successful laparoscopic seromyotomy (auto-augmentation) with resultant cure of his incontinence. The ability to perform this laparoscopically with its seventy-minute operating time, decreased hospital stay, and improved cosmesis militates for its consideration before a standard augmentation is performed.

The uretero-ileoceco-proctostomy (ileocecal rectal bladder): early experiences in 18 patients

With the current practice of continent urinary diversion the patient still has a cutaneous stoma and must perform intermittent catheterization. To circumvent these problems we devised the uretero-ileoceco-proctostomy (ileocecal rectal bladder), in which the intussuscepted ileocecal segment is interposed between the ureters and rectum, the rectal capacity is augmented by side-to-side anastomosis to the cecal limb of the segment and continence is controlled by the anal sphincter. The interposed segment prevents reflux of the urine-fecal mixture to the upper urinary tract and may decrease the risk of carcinoma at the ureteroileal anastomosis. The intussusception is stabilized without opening the recipient bowel (cecal limb), thus simplifying the subsequent ceco-proctostomy with automatic suture technique. Our preliminary experience in 18 patients with this new technique is encouraging with respect to voiding, preservation of renal function and quality of life.

Ureteral bladder augmentation

Virtually all segments of the gastrointestinal tract have been used successfully in augmentation cystoplasty. The complications inherent in enterocystoplasty are well described. Megaureters subtending effete kidneys (poorly or nonfunctioning) provide a novel and excellent source of augmentation material with urothelium and muscular backing, free of the electrolyte and acid base disturbances, and mucus production that plague enterocystoplasty. Augmentation cystoplasty using detubularized, reconfigured, otherwise disposable megaureter, with or without ipsilateral total or partial nephrectomy, was performed in 16 patients (mean age 8.8 years, range 1 to 25) with inadequate and dysfunctional bladders. Postoperative followup varied between 8 and 38 months (mean 22). The overall renal function and radiographic appearance of the remaining upper tracts have remained stable or improved in all patients. Of the 16 patients 15 require intermittent catheterization and 1 voids spontaneously. Ten patients are continent day and night, 5 have improved continence (4 damp at night and 1 stress incontinence) and 1 has failed to gain continence despite good capacity and compliance. Complete postoperative urodynamic evaluations in 12 of 13 patients show good capacity, low pressure bladders with no instability. Complications occurred in 5 patients, including transient urine extravasation in 2, contralateral ureterovesical obstruction in 2 and Mitrofanoff stomal stenosis in 1. Augmentation ureterocystoplasty combines the benefits common to all enterocystoplasties without adding any of the untoward complications or risks associated with nonurothelial augmentations.

The development of tumors in experimental gastroenterocystoplasty

Bladder augmentation with segments of the gastrointestinal tract is commonly used to treat patients with small or noncompliant bladders. Reliable data on the incidence of tumors in patients with enterocystoplasty are not available. In the small number of cases reported in the literature the mean latency period is approximately 18 years. We designed a study in Sprague Dawley rats to try to determine the risk of carcinogenesis in different types of augmentation cystoplasty and its possible relationship with infected urine, and to investigate the possibility of detecting the tumors by cytological analysis. We performed 30 gastrocystoplasties, 35 sigmoid cystoplasties, 30 ileocystoplasties and 10 sham operations, and used 10 nonoperated animals as controls. The animals were sacrificed upon completing 1 year of followup and bladder urine samples were collected at the time of sacrifice. Of 115 animals 86 were available for histological evaluation (26 gastrocystoplasty, 22 sigmoid cystoplasty, 18 ileocystoplasty, and all sham and control animals). Mean followup was 11.2 months in the gastrocystoplasty, 11.8 months in the sigmoid cystoplasty, and 12 months in the ileocystoplasty, sham and control groups. Multifocal or superficial transitional metaplasia was found in 65.4% of the gastrocystoplasty, 50% of the sigmoid cystoplasty and 55.5% of the ileocystoplasty animals. Proliferations that we classified as papillary hyperplasia were present in 53.8% of the gastrocystoplasty, 40.9% of the sigmoid cystoplasty and none of the ileocystoplasty rats. The proliferations occurred either at or close to the anastomosis between the bladder and the gastric or colonic patch, or in areas of transitional metaplasia. Cytological urinalysis was negative for neoplastic cells in all cases. No correlation was found between the occurrence of papillary hyperplasia and urinary infection. These data indicate that in rats transitional metaplasia is common in gastrocystoplasty, sigmoid cystoplasty and ileocystoplasty, and that papillary hyperplasia may occur near or at the anastomosis, or in areas of transitional metaplasia in either gastrocytoplasty or sigmoid cystoplasty. In contrast to other studies, we observed no examples of papillary hyperplasia in the ileocystoplasty group in this series. No transitional cell carcinomas or adenocarcinomas were identified in this study. It is not known if these papillary lesions have an increased malignant potential, thus further studies with longer followup are warranted.

Urothelial tissue culture for bladder reconstruction: an experimental study

An in vitro system for the growth of normal human urothelial cells has been developed. Urothelial cells were isolated from tissue samples in 38 patients and cultured in a defined serum-free medium. Confluent cell monolayers of 25 cm.2 were produced after 7 days in 32 cases. Subsequent subcultures at a 1:20 split ratio achieved confluency within another 7 days and a consistently high rate of growth was sustained for at least 7 passages. Characterization by immunofluorescence with a panel of antibodies demonstrated that the cultured cells were exclusively epithelial and retained the characteristic antigenic profile of normal urothelium, even after extended periods in culture. The only consistent cause of failure (6 of 38 cases) was bacterial contamination secondary to an underlying urinary tract infection in these patients.

Bladder Z-plasty for the repair of ureteric injuries. Experimental study in sheep

There is general acceptance that the best substitute for a damaged distal ureter is an elongated bladder and that the bladder psoas hitch is the most reliable procedure. Nevertheless, it is not always sufficient to bridge a long ureteric gap. In order to obtain an equally safe but wider bladder elongation than the psoas hitch can provide, we have previously studied the effect of several Z-shaped incisions on isolated pig bladders. The aim of the present study was to verify, in vivo, the efficacy and safety of the new technique. Five sheep underwent the psoas hitch procedure and 6 the Z-plasty procedure. The results showed that Z-plasty provides an equally safe but longer bladder elongation than the psoas hitch procedure.

Augmentation ureterocystoplasty

Augmentation cystoplasy using the gastrointestinal tract has disadvantages related to the intestinal resection and its incorporation into the urinary tract. To preclude both sets of complications, we performed augmentation ureterocystoplasty in a 5 1/2-year-old meningomyelocele patient with urinary incontinence, a low capacity bladder, severe vesicoureteral reflux and a poorly functioning kidney. After nephrectomy the ureter was incised longitudinally, folded over and placed onto the bladder as a patch. Bladder capacity, only 60 cc without the contribution from the refluxing upper tract, increased to 200 cc 6 months postoperatively. The patient is continent. Augmentation ureterocystoplasty is an option for bladder enlargement that obviates many of the risks associated with enterocystoplasty.

Ureterocystoplasty: a unique method for vesical augmentation in children

Vesical augmentation may be accomplished by using small bowel, large bowel or stomach, and by detrusor myotomy or the autoaugmentation technique. The use of intestinal segments is associated with variable mucus production, electrolyte absorption and the risk of malignant transformation. Autoaugmentation is free of these potential risks but may be unsuccessful in creating sufficient improvement in vesical compliance and capacity. Ureterocystoplasty with a bladder based native ureteral flap has been used in neurovesical dysfunction in association with a nonfunctional refluxing kidney, in a noncompliant valve bladder associated with posterior urethral valves and a nonfunctional kidney, and in augmentation of a small bladder after closure of cloacal exstrophy. Adequate bladder capacity and compliance have been achieved without the use of extra urinary epithelium. The surgical approach is simple and uncomplicated. Ureterocystoplasty in selected cases will provide for adequate bladder capacity and compliance when augmentation cystoplasty is required.

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.

Late malignancy risk in urology

The long-term survival of children with congenital urological abnormalities is now taken for granted. In general, they have been found to grow up well after many operations and often in the face of considerable handicaps. Their survival carries with it numerous complications, the most frightening of which is the development of cancer. Successful treatment of congenital abnormalities does not excuse the patient from developing cancers to which the general population is prone, but some conditions and some treatments raise specific risks.

Synchronous adenocarcinoma and transitional cell carcinoma of the bladder associated with augmentation: case report and review of the literature

We report a case of synchronous transitional cell carcinoma and adenocarcinoma in an augmented bladder 8 years after cecocystoplasty. We discuss the clinical presentation as well as current clinical and basic research concepts, and suggest that the anastomotic zone in such cases may be at risk for malignant transformation.

Continent cutaneous diversions in children: experience with the Mitrofanoff procedure

Continent cutaneous diversions with a urinary reservoir emptied by clean intermittent self-catheterisation (CISC) using a non-refluxing conduit--the Mitrofanoff principle--were carried out in 10 children. Their age range was 3.9 to 17.1 years (average 12.2). The underlying diagnoses were ectopia vesicae (7), myelodysplasia (2) and a cervical cord injury secondary to birth trauma (1). The indications were incontinence secondary to poor bladder neck resistance in 8 children and an inaccessible urethral orifice in 2. The catheterising conduits used were the appendix in 9 and a vascularised gastric tube in 1. Eight children are bone-dry with CISC. Another child needed a reoperation following dehiscence of her bladder neck closure. The other child has an intact bladder neck and urethra and occasionally leaks overnight. Mitrofanoff diversions are a reliable means of continence with CISC. This means of urinary diversion can be permanent or temporary in children who cannot or will not catheterise urethrally. Elective appendicectomy in children with potential urinary incontinence or complicated urogenital anomalies is not recommended.

Pathology of the urinary diversion

— The Authors describe the main pathological findings following urinary diversion, describing for each one the patho-physiological factors. The subjects are classified and treated following criteria proper to Urologic General Pathology (i.e. stasis, reflux, hydronephrosis, pyelonephritis, lithogenesis, carcinogenesis, etc.) rather than describing the relevant complications for each diversion.

Biodegradable pericardial implants for bladder augmentation: a 2.5-year study in dogs

Bladder augmentation using biodegradable pericardial tissue was evaluated in canine bladders. Acetic acid and acetic anhydride treated pericardial tissue grafts were stored in 75% ethanol for 18 to 27 months before implant. Ten dogs weighing 20 to 25 kg. were subjected to a 50% partial cystectomy. After careful separation of the mucosa, bladder muscle and adventitial layers a pericardial graft volumetrically equivalent to the portion of the bladder removed was sutured to the bladder remnant in 2 layers. In 1 control dog the bladder was opened, 50% of the bladder was removed and the bladder was closed primarily. In another control dog the excised bladder was replaced with fresh chemically treated patch material that was never subjected to ethanol storage. Excretory urography and cystography were performed on all dogs. Urodynamics with filling pressures and bladder volumes measured before and after the operation at intervals of up to 36 months confirmed that adequate bladder capacity was achieved. There were no operative complications. Postmortem histological evaluations revealed a smooth epithelialized inner surface with no traces of any surface irregularities or suture lines. The bladder apex showed an intact epithelium and the absence of a smooth muscle layer. The biodegradable acetylated tissue provides an intact structural reservoir for urine and serves as a template for epithelial regeneration. This permits volumetric bladder enlargement while the graft is progressively reabsorbed with time.

The influence of urinary diversion on experimental gastrocystoplasty

Gastrocystoplasty is used to augment the bladder of patients with decreased renal function to prevent development or worsening of metabolic acidosis. We recently observed a perforated peptic ulcer in the gastric portion of a defunctionalized gastrocystoplasty. We postulated that the lack of buffering action of urine precipitated peptic ulcer disease in the gastrocystoplasty. To explore this possibility further, we conducted an experiment. In 12 adult female mongrel dogs (weight 15 to 26 kg.) the bladder was divided into right and left segments. One kidney was removed and both hemibladders were capped with a vascularized segment of gastric body. Thus, 1 side (wet) remained exposed to urine, while the other side (dry) was drained to the abdominal wall with a cystostomy tube. The animals were divided into 2 groups: 9 in group 1 received no drugs to modify gastric secretion and 3 in group 2 received a hydrogen (H2) blocker. Three animals in group 1 had perforation of the vesical part of the dry gastrocystoplasty 2 to 3 weeks postoperatively and were sacrificed. The others were sacrificed 3 to 6 weeks postoperatively. Serum gastrin levels remained normal in all animals. Gross and histological examinations of the augmented bladders in group 1 revealed ulcerations of the bladder segment of the wet and dry gastrocystoplasties but the lesions were more numerous and prominent on the dry side in all animals, particularly those in which the perforations occurred. A peptic ulcer was noted in the gastric portion of the dry gastrocystoplasty in 1 animal. The bladder epithelium of the dry gastrocystoplasty showed glandular metaplasia in several animals in this group. In group 2 the wet gastrocystoplasty showed normal histology except in 1 dog that had mild inflammation and focal superficial ulceration in the vesical portion. On the other hand, the dry gastrocystoplasty showed severe inflammation and ulcerations in 2 animals, and mild inflammation of the vesical portion in 1. There were no perforations in this group. This experiment demonstrates that gastrocystoplasty produces cystitis but that these changes are more prominent in the absence of urine, as indicated by the severity of the lesions, perforations and metaplasia. Peptic ulcer disease occurred in the gastric portion of the dry gastrocystoplasty in 1 animal. The use of H2 blockers decreases the incidence of ulceration in wet gastrocystoplasty but it seems to have less influence on the ulceration of dry gastrocystoplasty. Clinicians must be alerted to the risk of perforation of dry gastrocystoplasty.

Villous adenoma in augmentation colocystoplasty: a case report and discussion of the pathogenesis

Reports of malignant tumors in enterocystoplasties have recently been accumulating. To date no case of benign tumors has been recorded. We present a case of villous adenoma in a sigmoid colocystoplasty. The possible etiological factors and pathogenesis are discussed, and recommendations are made about followup.

Clam ileocystoplasty

Clam enterocystoplasty has been used successfully in the treatment of refractory urge incontinence. We report 31 patients who underwent ileocystoplasty between 1982 and 1989. The majority of patients were pleased with the outcome of the operation. The main post-operative complication was voiding dysfunction due to relative bladder outflow obstruction. Urinary tract infection and mucus production were significant long-term problems.

Ileocecocystoplasty for the management of refractory neurogenic bladder: surgical technique and urodynamic findings

A total of 21 incontinent adults with a neurogenic bladder who were refractory to conservative management underwent a modified technique of ileocecocystoplasty. Followup ranged from 1 to 6 years (mean 3.1 years). To ensure a wide anastomosis the augmentation was accomplished by suturing a detubularized ileocecal patch to a large posterior based bladder flap anchored to the psoas muscles. Postoperatively 20 of 21 patients were continent. The remaining woman was cured after surgical correction of sphincteric incontinence. Mean bladder capacity increased from 185 +/- 17 to 595 +/- 43 ml. (standard error). Mean maximum detrusor pressure decreased from 53 +/- 6.3 to 16 +/- 2.3 cm. water (p less than 0.0001). Followup revealed a persistently large capacity, low pressure reservoir in all patients. No patient required anticholinergic medication. None experienced acid-base imbalance, tumors in the augmented bladder or upper tract deterioration. We conclude that this technique of ileocecocystoplasty is suitable for the management of patients with a refractory neurogenic bladder.

Unusual forms of carcinoma of the urinary bladder

Carcinomas of the urinary bladder, which differ histologically from the usual transitional cell carcinoma of the bladder, are reviewed. These tumors, which account for approximately 15% of all bladder carcinomas, have diverse microscopic appearances. They fall into four major categories: variant forms of urothelial (transitional cell) carcinoma, squamous cell carcinoma, adenocarcinoma, and undifferentiated carcinoma. In the first category, the most common are carcinomas with glandular or squamous differentiation. Less common, but more troublesome diagnostically, are variants in which the cells are spindle shaped (sarcomatoid carcinoma), form small cysts (microcystic carcinoma), or differentiate toward trophoblast. In other variants, the stroma has unusual features that may lead to diagnostic difficulty. These are carcinomas with pseudosarcomatous stroma, osseous or cartilaginous metaplasia, or osteoclast-type giant cells. Also reviewed are squamous cell carcinoma and its variant, verrucous carcinoma. Vesical adenocarcinoma has several variants, including signet-ring cell and clear cell types. Finally, the category of undifferentiated carcinoma, including small cell carcinoma, giant cell carcinoma, and lymphoepithelioma-like carcinoma, is discussed.

Tumor induction in a rat model for ureterosigmoidostomy without evidence of nitrosamine formation

Twenty rats were randomized into a vesicosigmoidostomy and an unoperated control group. In both groups the 24 hour excretion of secondary amines, nitrate, nitrite and nitrosamines was measured before and after gavage of proline and nitrate, piperazine and nitrate, N-nitrosoproline, mono-N-nitrosopiperazine. The urinary nitrosamine concentrations were not significantly different between both groups neither before nor after application of the several substances. Thirty rats were randomized into two vesicosigmoidostomy groups with and without antibiotic coverage and an unoperated control group. After ligation of distal rectum and mesosigmoid the rectosigmoids were removed. No significant concentrations of volatile nitrosamines could be measured in the rectosigmoid contents of the three groups. One hundred and twenty rats randomized into three groups following vesicosigmoidostomy received the potential nitrosamine antidotes sodium-2-mercaptoethane sulfonate or sodiumpentosan-polysulfate or acted as controls. 12/118 (10.2%) developed adenomas and 25/118 (21.2%) adenocarcinomas at the vesico-colonic anastomosis with no significant differences between the three groups concerning tumor incidence or mortality. The results show that colon carcinomas occur in a rat model for ureterosigmoidostomy without evidence for thus induced nitrosamine formation. This and the missing effect of nitrosamine antidotes suggest that other factors than nitrosation must be responsible for colon carcinogenesis following urinary diversion via intestine.

Complications of the Heitz-Boyer urinary diversion: case report of late development of malignancy

We report on 3 patients with bladder exstrophy followed for more than 15 years after having undergone Heitz-Boyer urinary diversion. One patient had adenocarcinoma at the ureterocolonic anastomoses 16 years after diversion. To our knowledge this is the first reported case of a malignancy developing after a Heitz-Boyer procedure. The other 2 patients had significant problems with urinary incontinence and recurrent urinary tract infections. Initial success with this form of urinary diversion can be followed by significant long-term complications.

Urothelial hyperplasia and neoplasia. III. Detection of nitrosamine production with different bacterial genera in chronic urinary tract infections of rats

Various agents have been implicated in inducing urothelial cancer. Although drugs, occupational and environmental carcinogens are more widely accepted as playing a major role as urothelial carcinogens, several investigations suggest that bacteria may play a role. The mechanism of how bacteria may interact with the host to augment the development of urothelial carcinoma is not well understood. Clinically, investigators have linked the development of infection, urinary stones and indwelling catheters with urothelial cancer. Other investigators have suggested that the mechanism may be related to the production of carcinogenic compounds (nitrosamines) which can be detected during urinary tract infection. In our laboratory, we showed that rats with chronic urinary tract infections produced increasing urinary levels of N,N dimethylnitrosamine over a 24 week period and that the production correlated with hyperplasia and early neoplasia of the bladder epithelium. Three bacterial genera were used and two of these (Escherichia coli and a protein sp.) showed production of increasing levels of urinary nitrosamine and correlated with infection. The purpose of this current study is to determine if other bacterial genera and strains can also produce similar increasing nitrosamine levels in the rat model of chronic urinary tract infection and thus provide evidence that a number of bacterial genera and strains can produce nitrosamines in vivo. Also, the histology of the chronically infected bladder was examined for hyperplasia and neoplasia.

The surgical management of urinary incontinence in myelodysplastic children

Over a 4-year period, 69 patients with intractable urinary incontinence secondary to myelodysplasia have undergone surgical therapy to try to achieve continence. Preoperative evaluation used uroradiological and urodynamic studies, including measurement of leak point pressure and leak point volume. Twenty-one patients had a procedure to increase outlet resistance, 30 patients had bladder augmentation, and 18 patients had both procedures performed. Fifty-seven of the 69 patients have achieved total continence for a success rate of 83%.