Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas

PURPOSE

Urethrovaginal fistulas are commonly repaired transvaginally with local tissue flaps, such as the Martius labial fat pad graft. Although this flap is ideal, if it fails and the fistula persists, subsequent treatment options are limited. We describe the use of a pedicled rectus abdominis muscle flap for the repair of complex and refractory urethrovaginal fistulas.

MATERIALS AND METHODS

Six women with a mean age of 53 years (range 41 to 62) who had complex and refractory urethrovaginal fistulas were referred to our continence center. Mean number of prior attempted repairs was 1.3 and in all cases at least 1 Martius flap had failed. Transvaginal urethrovaginal fistula closure was performed followed by a pedicled rectus abdominis muscle flap interposed between the fistula closure and vaginal suture line. The muscle flap was based on the inferior epigastric vessels, and provided additional support to the urethra, bladder neck and bladder base.

RESULTS

Urethrovaginal fistula repair with the rectus abdominis muscle flap was successful in all cases. No fistula recurred. Of the patients 5 (83%) were continent and able to void to completion at a mean followup of 23 months (range 2 to 66).

CONCLUSIONS

The rectus abdominis muscle flap is a useful adjunct in the repair of complex and refractory urethrovaginal fistulas. It can be used with confidence to provide support to the bladder neck and proximal urethra in patients after failed prior repair with the Martius flap procedure. The pelvic surgeon may be able to recognize other applications for the rectus abdominis muscle flap in pelvic floor reconstruction.

Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele

OBJECTIVES

To assess the functional and anatomic results of the paravaginal defect repair (PVdR) in women with stress urinary incontinence (SUI) due to bladder neck hypermobility (BNH) and cystocele.

METHODS

Fifty-two consecutive patients with a mean age of 61 years underwent PVdR for the treatment of SUI associated with BNH and varying degrees of vaginal prolapse. Twenty-five patients underwent PVdR alone (group 1), and 27 underwent PVdR in association with a rectus muscle sling (group 2) for the treatment of intrinsic sphincter deficiency. All patients had SUI and lateral defect cystocele (paravaginal defect). Associated vaginal and pelvic floor defects included rectocele in 34, vault prolapse in 24, and enterocele in 18; these defects were repaired simultaneously and had an equal distribution among the two groups.

RESULTS

At a mean follow-up of 17 months, the cure rate (defined as no pads and no leakage) was 79% (group 1, 72%; group 2, 85%). When expanded to include substantially improved (1 pad/day or less), the success rate was 88% (group 1, 84%; group 2, 93%). Recurrent vaginal prolapse occurred in 8 patients, 6 of whom had PVdR alone. For those patients with failure, time to recurrence of incontinence was 15 and 23 months in groups 1 and 2, respectively.

CONCLUSIONS

PVdR restores the normal lateral attachment of the pubocervical fascia to the arcus tendineous fascia pelvis of the pelvic sidewall and provides anatomic repair of lateral defect cystoceles. In women with anatomic SUI, PVdR restores continence by alleviating BNH and should be used in conjunction with a sling procedure in those with intrinsic sphincter deficiency.

Antegrade continence enema for the treatment of fecal incontinence in adults: use of gastric tube for catheterizable access to the descending colon

PURPOSE

We describe the use of a gastric segment in performing the antegrade continence enema procedure in patients with refractory fecal incontinence.

MATERIALS AND METHODS

The antegrade continence enema procedure was performed in 4 women and 3 men with refractory neurogenic fecal incontinence. Preoperative evaluation included defecography and anorectal manometry. Operative technique involves tunneling a 10 cm. segment of tubularized stomach isolated along the greater curve with preservation of the right gastroepiploic vessels through the anterior tenia of the colon just distal to the splenic flexure. After the stoma is mature the patient passes a catheter and runs 1 to 2 l. warm tap water through it while seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear.

RESULTS

Creation of a nonrefluxing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months all patients are continent and use antegrade continence enema irrigation every other day on average. One patient required early revision because of stomal stenosis. Special measures include application of a generic antacid tablet to the stoma and use of a skin barrier.

CONCLUSIONS

Catheterizable access to the descending colon for the antegrade continence enema procedure more closely approximates normal defecation patterns by emptying ("unloading") the left side of the colon. The stomach is a suitable option in close proximity for this purpose and is especially advantageous when the appendix is not available. The antegrade continence enema procedure using a gastric segment can be safely and effectively performed, and is well suited for use by reconstructive surgeons who are familiar with the Mitrofanoff principle.

Cecoappendicovesicostomy: conduit-lengthening technique for use in continent urinary reconstruction

OBJECTIVES

To describe a conduit-lengthening technique for use in continent cutaneous appendicovesicostomy (Mitrofanoff procedure).

METHODS

Fifteen consecutive patients (4 male, 11 female) with a mean age of 14.2 years underwent tubularized cecal augmentation as a means to lengthen the catheterizable conduit while performing continent cutaneous appendicovesicostomy.

RESULTS

All patients successfully underwent appendiceal lengthening by tubularizing the cecum, thus creating a continent cutaneous cecoappendicovesicostomy. With a mean follow-up of 18.7 months, all patients have a working catheterizable conduit. One case of stomal stenosis occurred, producing a 6.7% conduit-related complication rate.

CONCLUSIONS

Cecoappendicovesicostomy is a safe and useful means of conduit lengthening for patients undergoing continent cutaneous appendicovesicostomy (Mitrofanoff procedure).

Urolithiasis associated with the protease inhibitor indinavir

OBJECTIVES

To report the association between the protease inhibitor indinavir and the development of urolithiasis.

METHODS

Case reports of three adult patients infected with the human immunodeficiency virus who developed surgical renal stones while being treated with indinavir are presented.

RESULTS

Of the 3 patients requiring surgical intervention, stone analyses were available in 2. One stone revealed an inner core of an unidentifiable crystal surrounded by calcium oxalate, and another was found to have indinavir components as determined by thin-layer chromatography and gas chromatography-mass spectrometry. Metabolic evaluation of all 3 patients identified significant hypocitraturia as an isolated finding.

CONCLUSIONS

The widely used protease inhibitor indinavir is associated with the development of urolithiasis and may act as a nidus for heterogeneous nucleation leading to the development of mixed urinary stones. Surgical intervention may be necessary in some cases. Underlying metabolic abnormalities may contribute to the increased incidence of stone formation. Urologists and other health care providers should be aware of this association, as combined medical and surgical intervention may be necessary.

Bilateral ureteral obstruction associated with Henoch-Schoenlein purpura

Renal involvement is common in Henoch-Schoenlein purpura (HSP) and, while ureteral obstruction has been described in patients with the disease, it is rare. We report a female with HSP who developed bilateral ureteral obstruction from peri-ureteral vasculitis and subsequent ureteral ischemia. Hydronephrosis and typical findings on contrast urography indicated the diagnosis.

Single focus of adenocarcinoma in the prostate biopsy specimen is not predictive of the pathologic stage of disease

OBJECTIVES

To determine whether a very small focus of prostate cancer in a needle biopsy specimen correlates with organ-confined disease or with favorable disease parameters.

METHODS

Of 598 needle biopsies of the prostate performed from January 1990 through June 1994, 49 specimens (8.2%) contained a microscopic focus (less than 2 mm in length of the entire biopsy core specimen) of adenocarcinoma. For these 49 patients, the clinical and pathologic features were correlated.

RESULTS

Of these 49 patients, 27 (55.1%) underwent either radical prostatectomy, with or without pelvic lymph node dissection (26), or pelvic lymph node dissection alone (1). Seven of these 27 patients (25.9%) had extraprostatic disease: lymph node involvement (1), positive surgical margins (5), or seminal vesicle invasion (1). Ten of the 49 patients (20.4%) underwent radiotherapy, and 12 (24.5%) chose hormonal therapy. The pathologic stage for these 22 patients could not be ascertained. However, despite the limited amount of disease in the biopsy specimen, 2 patients treated with radiotherapy suffered a relapse (mean interval to recurrence, 11.5 months), and 3 patients treated with hormonal therapy (early or delayed) had bony metastasis at the time of diagnosis. Overall, 12 of the 49 patients (24.5%) had unfavorable disease (as defined by extraprostatic disease on pathologic specimen, relapse after radiotherapy, or bony metastasis at the time of diagnosis).

CONCLUSIONS

These findings suggest that a microscopic focus of prostatic adenocarcinoma in a needle biopsy specimen, per se, does not predict the pathologic stage or the biologic behavior of a tumor.

Rhabdomyolysis and acute renal failure following radical perineal prostatectomy

Rhabdomyolysis and acute renal failure can be a rare but serious complication resulting from compromising operative positions following some urologic and gynecologic procedures. We report a lethal case of rhabdomyolysis following radical perineal prostatectomy. The possibility of this complication must be considered prior to performing any operation in the exaggerated lithotomy position. Prevention, early diagnosis, and aggressive treatment are the keys to a successful recovery.

Kinetics of IgA plasma cells in the intestine of NIH mice infected with Trichinella spiralis

In uninfected mice, the percentage of IgA-containing cells labelled one day after a single injection of tritiated thymidine [( 3H] d Thd) was constant in the upper, middle and lower small intestine. In uninfected mice receiving an additional injection on the two preceding days there was about a threefold increase after the three injections indicating accumulation of labelled cells during the three day period. Five days after infection with Trichinella spiralis, the percentage of IgA cells labelled after a single injection of (3H)d Thd was increased at each site indicating increased division and, or, localisation of IgA cell precursors in the intestine. The numbers of cells labelled after three injections were reduced at this time, with no evidence of accumulation of further cells labelled from the two additional injections on previous days. By nine, 13 and 18 days after infection the numbers of IgA cells labelled after both single and triple injections were each increased, indicating increased division and, or, localisation of IgA precursors in the intestine with accumulation of labelled cells over the three day period resembling that in uninfected mice.

The in-vivo kinetics of lymphoblast localization in the small intestine

We have studied the in-vivo kinetics of the accumulation of 125I-UdR labelled mesenteric lymphoblasts in the small intestine of mice. The efficiency with which the labelled cells were extracted from the blood and retained by the intestine was quantified by examination of the accumulations observed over the first 4 hr after cell transfer. The kinetic parameters for the uptake and retention of lymphoblasts determined from these early times were found to provide a good approximation to the entire time course of accumulation observed from 1 hr to 22 hr after cell transfer. For normal mice, approximately 1% of lymphoblasts delivered by the blood stream at any given time gained entry to the small intestine and were retained with an average half-time of 6.5 hr. We also studied the accumulation of lymphoblasts in the small intestine of mice undergoing a self-limited enteric infection with the nematode, Trichinella spiralis. There was a greater accumulation of lymphoblasts in the small intestine of these animals. This was the consequence of a prolongation of the half-time for retention of lymphoblasts within the intestine to 15 hr, rather than increased uptake of lymphoblasts from the blood. During a secondary infection with T. spiralis, the half-time for retention of lymphoblasts in the intestine was decreased to 3 hr. These studies show that viewing the accumulation of lymphoblasts as the result of a series of first order kinetic processes provides a suitable model for the migration of lymphoblasts to the small intestine.

Development of the serological response in rabbits infected with Toxocara canis and Toxascaris leonina

The indirect fluorescent antibody test using frozen sections of infective Toxocara canis and Toxascaris leonina eggs, and the enzyme linked immunosorbent assay using homogenized Toxocara canis embryonated egg extract and T canis excretory-secretory products as adsorbed antigens were used to determine the specificity and development of circulating antibodies in rabbits. Frozen sections were subdivided into four morphologically distinct compartments for analysis of the development of the circulating antibody response. The fluid surrounding the larva was the most reactive up to 21 days after infection, and this material was found to be predominantly excretory-secretory in nature. As the infection progressed antibodies directed against 'somatic' tissue materials increased. Cross reactions between sera from rabbits infected with T. canis eggs and Toxascaris leonina frozen sections, and rabbits infected with T. leonina eggs and Toxocara canis frozen sections occurred between both the excretory-secretory fluid and somatic components of the infective eggs. These results were substantiated using the enzyme linked immunosorbent assay. When T. canis excretory-secretory antigen was used, an earlier response (peak day 21) was detected than when using T. canis embryonated egg extract (peak day 35). However, cross reactions between T. canis excretory-secretory antigen and sera from rabbits infected with Toxascaris leonina occurred, indicating that the serodiagnosis of visceral larva migrans using Toxocara canis excretory-secretory antigen may still prove unsatisfactory when considering the role of Toxascaris as a possible causative agent.

Intestinal mast cell response in thymectomised and normal mice infected with Trichinella spiralis

In NIH mice, expulsion of Trichinella spiralis from the small intestine and increase in intestinal mast cells were each dependent on the presence of T-lymphocytes. Both changes were deficient in thymectomised mice but could be largely restored by reconstitution of thymectomised mice with syngenetic mesenteric lymph node cells. In both NIH and BALB/C mice the majority of the increased number of mast cells occurred within the intestinal epithelium. In NIH mice increase in the number of intestinal mast cells coincided roughly with expulsion of the parasites. In BALB/C mice increase in the numbers of intestinal mast cells did not appear to be connected with the location or expulsion of parasites and it is concluded that mast cell proliferation, accumulation and discharge per se do not result in or from worm expulsion.

Reversibility of the effects of the host immune response on the intestinal phase of Trichinella spiralis in the mouse, following transplantation to a new host

On day 10 of a primary infection of Trichinella spiralis in NIH mice, when adult worms were in the process of being expelled, their fecundity was markedly depressed. Upon transplantation to new host mice, the worms were able to establish successfully in their usual position in the anterior small intestine, even if originally recovered from the large intestine of mice expelling their worms, and these worms fully recovered their fecundity after 7 days in recipients. On day 5 of secondary and tertiary infections, immediately before loss of worms began, the adult worms were stunted and had a depressed fecundity. However, such worms, when transplanted, were able to establish in normal numbers and in a normal position in the intestine of recipient mice. Additionally, these worms were found to have developed a fecundity, and grown to a length, comparable to that of normal worms, but slightly less than that of control worms transplanted from day 7 of a primary infection, after 7 days in a new host. Electron microscopy showed that worms taken at the time of expulsion in primary and tertiary infections showed structural abnormalities, including large quantities of lipid in intestinal cells and somatic musculature and decreased quantities of stored glycogen. Upon transplantation to new host mice, these worms were found to have recovered a normal ultrastructural appearance within 7 days, although there was still evidence of a slightly elevated lipid and depressed glycogen content. It is concluded that immune expulsion of T. spiralis from mice does not involve irreversible damage to the worms.

Regional blood flow and the localization of lymphoblasts in the small intestine of the mouse. II. The effects of a primary enteric infection with Trichinella spiralis

The localization of 125I-UdR-labelled mesenteric lymph node cells in the small intestine and the fraction of the cardiac output delivered to this organ in mice has been examined. Concurrent measurements of these two phenomena in normal animals showed that there was a significant correlation between the localization of lymphoblasts and the distribution of regional blood flow along the small intestine. In mice undergoing enteric infection with Trichinella spiralis, however, the nature of the connection between lymphoblast localization and blood flow distribution in the small intestine was altered. More lymphoblast label accumulated in the small intestine of infected mice than in uninfected animals even at stages of the infection when no alteration in the proportion of the cardiac output received by the small intestine had occurred. Enhanced lymphoblast accumulation occurred in different segments of the infected small intestine as the infection proceeded and these changes paralleled the way in which the parasite burden was distributed in the intestine. The kinetics of lymphoblast accumulation in infected and uninfected small intestine was examined under circumstances where the delivery of blood-borne labelled cells was the same. This showed that both increased entry of lymphoblasts and enhanced retention of lymphoblasts occurred in the parasitized small intestine.

Studies on the incidence of Toxocara and Toxascaris spp. ova in the environment. 1. A comparison of flotation procedures for recovering Toxocara spp. ova from soil

Seven different flotation fluids were assessed for their efficiency in recovering Toxocara canis ova from artificially seeded soil samples. Using the most efficient (a saturated solution of magnesium sulphate plus 5% potassium iodide) 25 g amounts of 234 environmental soil samples were examined for the presence of Toxocara spp. and Toxascaris ova. Twenty-six samples (11.1%) yielded ova of one or other species. There was no discernible pattern of distribution of positives with relation to the source of the samples. The maximum number of ova recovered in any one sample was 19. All the ova recovered from the environment were considered viable and potentially infective.

A paper radioimmunosorbent test (PRIST) for the detection of larva-specific antibodies to Toxocara canis in human sera

A paper radioimmunosorbent test (PRIST) was shown to be sensitive and reproducible when used with excretory/secretory antigen of Toxocara canis second stage larvae. Whatman No. 50 filter paper (5 mm discs) gave the most consistent and clear results with antigen at a concentration of 100 micrograms/ml, and could be stored for up to 3 weeks in vacuo at -70 degrees C. Antigen coated discs were incubated with test sera at 1:10 dilution for 3 h at room temperature (21 degrees C), reacted with [125I]anti-human IgG for 1 h and counts determined in a gamma counter. Sera from patients with fascioliasis, taeniasis, schistosomiasis, oxyuriasis, trichinellosis and ancyclostomiasis gave counts similar to cord serum controls. Sera from patients with ascariasis gave counts of up to twice as great as controls, but sera from patients with toxicariasis produced counts of 7,000-13,000, a 4-6-fold increase.

Migration of lymphoblasts to the small intestine. III. Strain differences and relationship to distribution and duration of Trichinella spiralis infection

In NIH strain mice, in which the majority of Trichinella spiralis are located in the anterior half of the small intestine early in the enteral phase of infection, enhanced localization of mesenteric lymphoblasts, nylon wool separated mesenteric T-lymphoblasts and even oxazolone sensitized peripheral lymphoblasts is most prominent in the anterior region of the small intestine. As the worms move to the posterior half of the small intestine, enahnced localization of lymphoblasts is observed in that region only. In BALB/c mice, in which most of the worms are located in the posterior half of the small intestine, enhanced localization of lymphoblasts is primarily in that region. Expulsion of the worms commences within 2--3 days of a large increase in the number of lymphoblasts localizing in the anterior region of the small intestine in NIH strain mice and likewise follows a second and larger increase in the number of lymphoblasts localizing in the posterior region of the small intestine of BALB/c mice.

The accumulation of immunoblasts in extravascular tissues including mammary gland, peritoneal cavity, gut and skin

The migration of [125I]UdR labelled mesenteric (MLN) and peripheral T immunoblasts (PLN) has been followed in mice with multiple sites attractive to immunoblasts. The sites studied were the inflamed gut (produced by Trichinella spiralis infection), inflamed skin, the peritoneal cavity and the mammary glands of lactating mice. PLN were capable of assembling in all of the four sites and in the presence of both inflamed gut and inflamed skin, PLN accumulated preferentially in the skin. MLN, in contrast migrated only to the gut and mammary glands and not to the skin or peritoneal cavity, and could not be diverted from one site to another. Time course experiments revealed that whereas PLN migrate rapidly through the inflamed gut, they are retained in the skin for at least 3 days.

I. Effect of Trichinella spiralis infection on the migration of mesenteric lymphoblasts and mesenteric T lymphoblasts in syngeneic mice

The migration of [125I]UdR-labelled mesenteric lymph node cells in NIH strain mice at various times after inis produced an enhanced accumulation of mesenteric immunoblasts in the small intestine at 2 and 4 days after infection but not at later times. The enhanced migration occurred when using cells from both uninfected and infected donors, denoting an absence of antigenic specificity. This effect is not secondary to a reduced arrival of cells at sites away from the gut in infected mice, but to a primary increase of the arrival in the small intestine. Mesenteric T lymphoblasts (separated on a nylon-wool column) migrated to the small intestine of uninfected recipients and appear to be a major portion of the population which migrate to the gut of infected recipients. Our results were confirmed using 51Cr to label mesenteric cells. We conclude that the parasite causes the small intestine to become more attractive or retentive for mesenteric blast cells early during infection.

Factors which determine the accumulation of immunoblasts in gut and skin

The capacity of immunoblasts from two sources (1) peripheral lymph nodes draining the site of application of a contact sensitizer and (2) mesenteric lymph nodes from mice infected with the gut parasite T. spiralis to migrate to the gut and to inflamed skin sites were compared. The peripheral lymph node blasts readily entered skin sites in a non-specific way but failed to migrate to the gut even when inflammation was induced. By contrast, the mesenteric lymph node blasts readily migrated to the gut in normal mice and in increased amounts to the gut of mice infected with T. spiralis or inflamed with oral turpentine. A small proportion of mesenteric lymph node blasts did, however, migrate, non-specifically to the skin but in much smaller amounts than peripheral lymph node blasts. We conclude that the migration of immunoblasts to the gut has some specificity related to the source from which the cells were taken but little specificity with regard to intraluminal antigen.

Inhibited development in Ostertagia ostertagi infections--a diapause phenomenon in a nematode

Experiments are described which show that in a recently isolated field strain of the cattle nematode, Ostertagia ostertagi, the primary stimulus to the induction of inhibited development at the early fourth larval stage (EL4) in the host is chilling of the infective larvae (L3). Thus exposure of L3 to a temperature of 4 °C for 8 weeks prior to their oral administration to calves resulted in a mean of 66% of the established worm burden becoming inhibited at the EL4 stage. This provides an explanation for the seasonal occurrence in Britain of inhibited EL4 stages of O. ostertagi in cattle during the cold climate of late autumn and winter.

If the L3 stages were exposed to chilling for a prolonged period (> 19 weeks), prior to infection of calves, then the prevalence of inhibited EL4 stages amongst the worms established declined. After 33 weeks chilling the worm population consisted almost entirely of adults and only 2% inhibited EL4 stages. This suggested that a selective mortality of inhibition prone L3 was taking place and explained why under natural grazing conditions inhibition prone L3 were not available on the pasture in spring.

The duration of inhibition at the EL4 stage in calves infected with chilled L3 was consistently between 16 and 18 weeks and maturation of the majority of the inhibited larvae occurred spontaneously after such a period and irrespective of season. This period is equivalent to the duration of a normal winter in Britain when conditions unsuitable for the free living development of O. ostertagi larvae prevail.

The induction of inhibition by the environmental stimulus of chilling, the fixed period for the duration of inhibition within the host and the spontaneous maturation of the inhibited larvae are characteristic of a true diapause.

The structure and composition of the capsule of Trichinella spiralis in host muscle

The results of ultrastructural studies and histochemical tests on the capsule of Trichinella spiralis are given. The capsule wall is shown to consist of two layers, an outer region of tightly compacted fibrils and an inner region of fibrils dispersed through matrix cytoplasm. Histochemical tests show the capsule wall to consist mainly of collagen and cystine. The appearance of the matrix, which is packed with mitochondria, rough endoplasmic reticulum, smooth reticulum and Golgi complexes, together with the histochemical reaction to the five enzymes tested, strongly suggests that the matrix is a region of high metabolic activity. Although there are several very large nuclei in the matrix there is no evidence of cell walls; consequently the matrix is a syncytium.

I wish to thank the A.R.C. for financial support while this work was carried out. I should also like to thank Dr D. L. Lee for his advice on many occasions and the late Professor Boyd of the Anatomy Department, University of Cambridge, for the use of the electron microscope in that Department.

A study of the gastro-intestinal worm burden in grazing ewes

The worm burden in grazing ewes was studied. Analysis of the results showed that correcting worm egg counts (e.p.g. fresh faeces) for variations in faecal D.M. content and in total faeces output is not of any great benefit unless precise information is available.

Data are also presented which suggest that under normal circumstances variations in the sub-clinical worm burden of adult grazing ewes are not related to any variations in food intake.

The fine structure of the intestine and hind gut of the larva of Trichinella spiralis

The brush border of the intestinal cells of the infective larva of Trichinella spiralis is shown to consist of microvilli. It is suggested that large vesicular complexes in association with Golgi complexes may be responsible for the production of the mucopolysaccharide or mucoprotein filling the lumen of the intestine. Indirect evidence of a latent intranuclear virus infection is presented. The cuticle lining the hind gut, although continuous with the external cuticle, is not similar in structure.

I would like to thank Dr D. L. Lee for instruction in all aspects of this work, Professor Boyd for the use of the Anatomy Department electron microscope and the Agricultural Research Council for financial support.