Urethral controlled bladder substitution: a comparison between Parks S pouch and hemi-Kock pouch

To study the effect of the configuration of ileal reservoirs on the urodynamic features, 12 S bladders and 12 Kock pouches were compared. Volume capacity and pressure characteristics were studied 6 months postoperatively. The mean capacity of the reservoirs was 500 +/- 83 ml. for the S bladder and 536 +/- 56 ml. for the Kock pouch. The amplitudes of phasic contractions at 50%, 80% and 100% capacity were similar in both groups. However, the frequency of these contractions was higher in the S bladder. The intraluminal pressure at full capacity was 31 +/- 15 cm. water for the S bladder and 39 +/- 20 cm. water for the Kock pouch. The similar urodynamic features of the S and Kock pouches indicate their ultimate expansion into reservoirs of close physical characteristics and urodynamic behavior.     

Vitamin B12 Deficiency in Patients with Urinary Intestinal Diversion

Background Because vitamin B₁₂ is absorbed exclusively by the terminal ileum, we investigated vitamin B₁₂ deficiency as a potential metabolic complication after urinary intestinal diversion.
Methods We measured serum levels in patients with Kock pouches (n = 35); Indiana pouches (n = 27); and ileal conduits (n = 25). Serial determinations of serum B₁₂ levels were obtained in 1 9 patients with Kock pouches and 14 patients with Indiana pouches. The dual-isotope Schilling test was performed in 9 patients with Kock pouches and 6 patients with Indiana pouches.
Results No patient had an abnormally low serum B₁₂ level (< 200 pg/mL). Mean (+ SD) serum B₁₂ levels in patients with the Kock pouch (506 ± 202pg/mL) and the Indiana pouch (536 + 249pg/mL) were lower than that in patients with the ileal conduit (727 + 391 pg/mL). The mean serum B,₂ level was not significantly different between patients with and without preoperative irradiation. Serial determinations showed that serum B₁₂ levels in some patients with continent urinary reservoirs were persistently near the lower normal limit, or became progressively lower. Three of the 9 patients (33%) with Kock pouches and 4 of the 6 patients (67%) with Indiana pouches were B₁₂ malabsorbers, although no patients had megaloblastic anemia or neurologic symptoms.
Conclusions Some patients with continent urinary reservoirs are at risk for vitamin B₁₂ deficiency due to malabsorption. Routine evaluation of serum B₁₂ levels is recommended for all patients with continent urinary reservoirs, and a Schilling test for those with subnormal serum B₁₂ levels.     

Effects of atropine,glucagon, and bethanechol on urodynamics of continent cecal urinary reservoir before and after complete,partial, and sham detubularizations in dog

Effects of muscarinic receptor blockade (atropine), stimulation (bethanechol), and bowel smooth muscle relaxant (glucagon) on the Urodynamics of the continent cecal urinary reservoir in a tube form and after complete, partial, and sham detubularizations were studied using dogs. Complete detubularization significantly increased capacity and decreased spontaneous motor activity, whereas the other types of detubularization had no significant effects on them. Neither atropine nor glucagon had influence on the basal pressure, but they increased the capacity and the volume at which the first pressure wave appeared and decreased the wave amplitude. After detubularization glucagon further decreased uninhibited contractions while atropine totally abolished them. The highest capacity and lowest motor activity was gained when atropine or glucagon was given in cases with detubularized pouch demonstrating an additive effect of the detubularization and drug. Also, bethanechol increased the motor activity and decreased the volume in detubularized pouches. It is suggested that when hyperactivity of intestinal reservoir is a problem in a patient with a detubularized cecal pouch, orally administered anticholinergic or bowel smooth muscle relaxing drugs may be useful in management. © 1993 Wiley-Liss, Inc.     

Clinical evaluation on Le Duc-Camey antireflux ureteroileal implantation

Le Duc-Camey antireflux ureteroileal implantation was evaluated clinically; by applying to various types of urinary reconstruction utilizing the ileum. Nineteen ureters in 10 cases including five Kock continent ileal urinary reservoirs (Kock pouches); five ileal conduit urinary diversions and one Goodwin ileocystoplasty were performed from March 1987 to August 1988. Male and female ratio was 8 to 2 and the average age was 61.7 years old. The post operative observation period was 13.9 months on the average. The outline of the operative procedure was as follows: a 3 cm sulcus was created in the mucosa along the long axis of the ileum; the ureter was passed from the serosal surface to the luminal surface and the adventitia of the ureter and the mucosa were sutured at three points in each side using 3-0 absorbable ligature to implant the ureter in the mucosal sulcus. The ureteral end was spatulated 3 mm in the upper wall and it was fixed to the mucosa by three stitches. A ureteral stent catheter, 7-8 Fr. in diameter, was indwelled in the ureter. Additional stitches were placed to strengthen the fixation on the outside surface of Kock pouches or a Goodwin ileocystoplasty. The afferent limb was not fabricated in Kock pouches because ileoureteral reflux could be prevented by the implantation technique on the pouch. Radiological evaluation was done taking IVP, loopography, pouchgraphy and cytography periodically after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Contractile function of upper urinary tract after indwelling ureteral prosthesis: experimental investigation

BACKGROUND: Ureteral endoprostheses are used for dilatation of strictures in order to maintain upper urinary tract (UUT) function for a longer period. MATERIALS AND METHODS: Three kinds of short (3-4-cm) endoprostheses were inserted into the ureter of mongrel dogs with intact UUT or experimental ureter strictures. The UUT function was evaluated by means of radiographic examinations and in terms of following measures of contractility: intraluminal pressure, electroureterography (EUG), and multichannel impedance ureterography (MIUG). Studies were performed 1, 3 to 6 months, and 1 to 3 years after prostheses implantation. RESULTS: Similar urodynamic changes were registered in prosthetically treated ureters of dogs with initially intact UUTs and those with ureteral strictures. These disorders consisted of increased UUT intraluminal pressure and different functioning of the upper and lower regions of the ureter. The bioelectric and contractile activity of the upper UUT regions was reinforced, accelerated, and dysrhythmic, while peristaltic ureter wall function below the endoprosthesis was rare and weak. CONCLUSIONS: The changes observed are typical for ureteral prosthetics. The UUT urodynamic alterations could be attributable entirely to the excluding of the ureteral segment from active contraction and were the result of the local absence of the ureteral wall closing mechanism. One must keep in mind that UUT endoprostheses produce a high load on the ureter wall. The transition from UUT hyperfunction to contractile function decompensation may depend on the intrinsic compensatory reserves of the ureter.     

Effects of terodiline on lower urinary tract function

The effects of terodiline on lower urinary tract function were studied using decerebrated dogs. The micturition cycles were investigated by pressure flow EMG study before and after the administration of terodiline. The statistical analysis was carried out on the urodynamic parameter. Terodiline at a dose of 1 mg/kg decreased the opening pressure, contraction pressure, and flow rate and increased the residual volume. A decrease in threshold pressure, average flow rate and an increase in bladder compliance also occurred after the administration of terodiline at the dose of 3 mg/kg. Terodiline appears to decrease bladder activity and is useful for pollakisuria.     

Potential for left ventricular assistance by latissimus dorsi myograft--sequential effects of electrical preconditioning on skeletal muscle fiber type, blood flow and metabolic status

In order to evaluate the possibility of left ventricular assistance by latissimus dorsi (LD) myograft, we have studied contractile property and fatigue rates of skeletal muscle ventricle (SMV) constructed using canine LD muscles. Twenty three dogs were divided into 3 groups depending on the conditioning protocol of LD muscles; Group I (Control n = 12), Group II (Vascular delay n = 4) and Group III (Vascular delay and electrical preconditioning n = 7). SMVs in GIII dogs generated sufficient pressure and forward flow in a hydraulic test system with muscle stimulation at a burst-frequency of 50 Hz (SMV pressure 131 +/- 42 mmHg, Stroke volume 7.0 +/- 3.0 ml/beat). Although SMVs in GI and GII dogs could sustain flow for only 4.0 +/- 1.1 minutes and 32.4 +/- 14.0 minutes, respectively, SMVs in GIII were able to pump continuously for 107.5 +/- 15.0 minutes (p less than 0.01, vs GI and GII). Thermography surface temperature mapping revealed marked improvement of blood distribution of LD muscles in GII and GIII dogs. Flow rates of thoracodorsal artery during SMV stimulation were GI: 10.0 +/- 3.1 ml/minute/LD 100 g, GII: 15.0 +/- 3.7 ml/minutes/100 g and GIII: 20.7 +/- 2.5 ml/minutes/100 g (p less than 0.01 vs GI). The ratio of oxygen consumption to lactate output was GI: 0.33 +/- 0.10, GII: 0.36 +/- 0.09 and GIII: 1.56 +/- 0.97 (p less than 0.01 vs GI, p less than 0.05 vs GII). Histochemical examination of LD muscles using alkaline ATPase stain revealed muscle fiber type transformation of GIII muscles. These results suggest electrically preconditioned LD muscles have sufficient contractile property for partial left ventricular assistance, and highly fatigue-resistant properties resulted from muscle fiber transformation, improved muscle perfusion and metabolic changes.     

Endothelial Lined Skeletal Muscle Ventricles: Open and Percutaneous Seeding Techniques

Twelve bilateral skeletal muscle ventricles (SMVs) were constructed in six dogs by wrapping each latissimus dorsi muscle around a cylindrical, plastic mandrel (volume 30 cc). After 6 to 10 weeks, five dogs had one of their SMVs seeded with allogeneic cultured canine endothelial cells (8 times 10⁶ cells/pouch) via an open technique, while the contralateral SMV was seeded by percutaneous injection of cells into the space around the mandrel. After 1 week, the SMVs were excised. Viable, adherent endothelial cells were present in all seeded pouches; this was confirmed via fluorescent microscopy with several endothelial cell markers: KLH-2, dilacetylated low-density lipoprotein and antibodies to von Willebrand factor. The inner lining of the SMVs were also examined with scanning and transmission electron microscopy; the highest concentration of cells were seen at the apex where a continuous endothelial monolayer was observed. No significant difference in the distribution or the morphology of the endothelial lining was noted between the open and percutaneous seeding techniques. These data show that SMVs can be seeded with an endothelial monolayer using both open and percutaneous techniques.     

Effect of oxybutynin on lower urinary tract function

The effect of oxybutynin on lower urinary tract function was studied by combined recording of cystometry and sphincter electromyogram (EMG) in 7 decerebrate dogs. Micturition was induced by bladder filling before and after oxybutynin. The statistical analysis was carried out on the urodynamic parameters. Oxybutynin at a dose of 30, 100, and 300 micrograms/kg significantly increased the threshold volume during the collecting phase in a dose dependent manner. In the urodynamic parameters of the emptying phase considered to be influenced by cholinergic activity there was a small but significant decrease in maximum pressure only at 300 micrograms/kg. Therefore, oxybutynin is probably acting as a strong antispasmodic agent. Oxybutynin seems to be useful for the relief of symptoms associated with detrusor instability and hyperreflexia.     

Experimental study on potential for cardiac assist by latissimus dorsi myograft--an importance of muscle ischemia

We have studied contractile property and fatigue rates of skeletal muscle ventricle (SMV) constructed using the latissimus dorsi muscles of 11 dogs. The role of early interruption of collateral blood supply in the prevention of muscle ischemia and SMV fatigue was evaluated. Systolic function of SMV was measured in a hydraulic test system; afterload was set at 70 mmHg and preload 15 or 25 mmHg. Control SMV (GI: N = 7), which was fashioned immediately after interruption of collateral blood supply, generated an initial SMV pressure of 222 +/- 50 mmHg and stroke volume of 15 +/- 7 ml/beat with muscle stimulation at a burst-frequency of 50 Hz, but could sustain flow for only 3.5 +/- 0.8 minutes. SMV subjected to a vascular delay (Group II: N = 4) demonstrated improvement of fatigue rates; duration of flow 32.4 +/- 14.0 and sufficient contractile property (initial SMV pressure 182 +/- 17 mmHg, stroke volume 1- +/- 2 ml/beat). Thermography surface temperature mapping revealed remarkable improvement of blood distribution in GII muscles. Flow rates of thoracodorsal artery were significantly greater in GII muscles compared to those in GI muscles (15.0 +/- 3.7 ml/min/LD 100 g, 10.1 +/- 3.1 ml/min/LD 100 g, p less than 0.05, respectively). Despite significant improvement of functional durability in GII muscles, the ratio of oxygen consumption to lactate output was not different between 2 groups. These results suggest that early interruption of collateral blood supply can minimize muscle ischemia, resulting in diminishing fatigue of latissimus dorsi muscles without changes in skeletal muscle metabolism.     

Can simultaneous perineal sonography and urethrocystometry help explain urethral pressure variations?

Objective: To correlate urodynamic with perineal sonographic findings in pressure variations. Patients and methods: In 15 women presenting with urethral pressure variations a urodynamic evaluation with water filling cystometry, urethral pressure at rest and during coughing and uroflowmetry were performed. During water filling cystometry, there were simultaneous perineal video-sonography and urethrocystometry. Video ultrasound images and urodynamic curves were simultaneously monitored on a computer screen. Results: Simultaneous ultrasound and urodynamic evaluation in the 15 patients revealed movements in two areas leading to urethral pressure variations: activity of the pelvic floor muscles and of the urethral sphincter muscles. For the pelvic floor, we found either slow or fast contractions with, respectively, slow (15–30 cm H₂O for 3–10 sec) or fast (30–130 cm H₂O for 1–3 sec) urethral pressure changes. Urethral sphincter contractions were always fast, resulting in fast pressure changes of 30–170 cm H₂O for 1–3 sec. Conclusion: Evaluation of simultaneous perineal sonography and urethrocystometry shows the association of urethral pressure variations and muscle activity. Urethral pressure variations are caused by the activity of urethral sphincter or pelvic floor muscles. With ultrasound the activity of the urethral sphincter muscle can directly be seen whereas pelvic floor muscle activity is indirectly visible. Pelvic floor muscle contractions are either fast or slow, whereas the urethral sphincter muscle contractions are always fast contractions.     

Pelvectomy and continent diversion

We owe to N.G. Kock and to M. Camey the extraordinary recent development of continent urinary diversion and of bladder replacement. During sixty-six months, 145 Kock pouches were constructed: 79 for continent cutaneous diversion (44 men, 35 women), 54 bladder replacements by men, 12 ileo-rectal diversions (10 women, 2 men). The mortality during the six first postoperative weeks reaches 6/145 patients (4.13%). 17 patients out of c139 (12.23%) presented postoperative complications; 15 patients required surgical revision (10.70%)(10 intestinal obstructions).     

Effect of partial urethral obstruction on force development of the guinea pig bladder

We created gradual partial urethral obstruction in 20 guinea pigs using silver jeweler's jump rings. After 4 or 8 weeks obstruction all animals underwent cystometry and were assigned to one of five urodynamic categories: normal, high pressure voiding, unstable, low compliance, or decompensated. After sacrifice, the contractile responses of bladder strips to electrical field stimulation of intramural nerves, direct electrical muscle stimulation, 0.1 mM carbachol, and high K + solution were sampled by computer for phase plot analysis. Following 8 weeks obstruction, the value of the phase plot parameter Fiso, indicative of the number of contractile muscle units, was reduced to 60% of the control response to nerve stimulation (P < 0.05) and to 77% of the control response to carbachol stimulation (P < 0.05). Parameter C, the slope of the phase plot (indicative of unit recruitment during force development), was unchanged for all forms of stimulation. Although in the latter case not statistically significant, obstruction affected responses to nerve and muscle stimulation similarly suggesting that muscle change may possibly be a common denominator of dysfunction. In view of the reduction in Fiso and the increase in bladder weight, instability may represent a more advanced form of dysfunction due to obstruction than high pressure voiding.     

Differential effect of nitric oxide synthase inhibition on sigmoid colon longitudinal and circular muscle responses to nicotine and nerve stimulation in vitro

BACKGROUND: Nicotine has been shown to release nitric oxide from nerves in human sigmoid colon. This effect has been used to investigate the innervation and functional relationship of the longitudinal and circular muscle layers. METHODS: Strips of longitudinal and circular muscle were obtained from 19 patients with colorectal cancer. The strips from ten patients were subjected to electrical field stimulation (EFS) in vitro using stimulus parameters for selective stimulation of nerves. The effect of nicotine 1-10 micromol/l on EFS responses was then measured in the presence and absence of a nitric oxide synthase inhibitor, nitro-L-arginine methyl ester (L-NAME) 200 micromol/l. The effect of nicotine on spontaneous activity was investigated in the muscle strips from the other nine patients. RESULTS: Both longitudinal and circular strips responded to EFS with contraction. The time to achieve a peak contractile response (time to peak; TTP) was significantly longer (P<0.001) in circular strips. L-NAME reduced the mean(s.e.m.) TTP in circular muscle from 23.3(2.0) to 17.2(1.5) s (P=0.007) and altered its pattern of response to resemble that of longitudinal muscle. Nicotine 10 micromol/l reduced the contraction to EFS in circular (P<0.001) but not in longitudinal (P=0.347) muscle. The nicotine-induced reduction in circular muscle contraction was blocked by L-NAME 200 micromol/l (P=0.005). CONCLUSION: These findings suggest that nitric oxide release on neural stimulation is greater in circular than in longitudinal muscle.     

Adrenergic influences on the voiding cycle in the decerebrated dog

Adrenergic influences on the voiding cycle were clarified by the modern urodynamic technique of pressure flow electromyogram study in 20 decerebrated dogs. A series of experiments were performed before and after hypogastric nerve transection. Similar experiments were done before and after pharmacologic blockade of α- and β-adrenergic receptors. In the control condition, reflex micturition occurred when a critical degree of filling was reached. After hypogastric nerve transection or administration of phentolamine or propranolol, reflex micturition still occurred. However, hypogastric nerve transection, phentolamine, and propranolot produced significant changes in the values of some urodynamic parameters. It appears that adrenergic function plays a definite role in the voiding cycle of the decerebrated dog by regulation of bladder and ureihral smooth muscle activity.     

Restoring voluntary urinary voiding using a latissimus dorsi muscle free flap for bladder reconstruction.

We present our data using innervated latissimus dorsi muscle (LDM) free flaps to assist acontractile bladder function. Twelve dogs were used. In group I (n = 3), the LDM flaps were elevated and wrapped around silicon reservoirs; in group II (n = 4), the LDM flaps were transferred into the pelvis and used to reconstruct bladders that had 50% of their detrusor muscle wall removed; group III (n = 5) was the same setup as group II but the bladder mucosa was also removed with 50% detrusor wall. The LDM flaps were electrically stimulated and electromyography, cystography, urodynamic, and hydrodynamic measurements were performed. In clinical studies, LDM flaps were used in 11 patients (age range, 9-68 years). Our animal studies demonstrated that LDM flaps are capable of generating pressures (190 cm H(2)O at 15 mL and 35 cm H(2)O at a 10 mL in group I at 6 months) to void the bladder. In group II, contractions were present after 9 months. Eight of 11 patients who underwent LDM free flap were able to void voluntarily and without catheterization. LDM flap activity was confirmed using ultrasonography/tomography. Our clinical studies indicated that contractile function can be restored using LDM free flaps.     

URINARY BACTERIOLOGY OF CONTINENT URINARY RESERVOIRS AND CALCULUS FORMATION

In order to investigate urinary bacteriology in relation to calculus formation in continent urinary reservoirs, a retrospective study was conducted of 19 patients with the Kock pouch and 23 patients with the Indiana pouch. Analysis of a total of 151 urine-cultures showed that asymptomatic bacteria (any bacterial count) were present in 92% of urines from the Kock pouch and 74% from the Indiana pouch. The incidence of organisms and total bacterial counts were similar for both pouches. The most prevalent organisms were Escherichia coli, Pseudomonas sp., Klebsiella sp., Proteus sp., Enterobacter sp., and Enterococcus sp. Urinary calculi developed in 42% of the Kock pouch patients and 13% of the Indiana pouch patients. More than half of the patients had multiple stone recurrence. Infectious stones developed in 32% of the Kock pouch patients, usually on the foreign materials, and 9% of the Indiana pouch patients. In general, no clear relationship was established between urinary bacteriology and calculus formation although Proteus sp. or Providencia sp. was determined to be the causative organism in some infectious stones. Furthermore, metabolic stones developed in 32% of the Kock pouch patients and 9% of the Indiana pouch patients. Because calcium phosphate was a constituent of 80% of the metabolic stones, the presence of urinary factors promoting calculus formation was suspected.     

Halothane changes the relationships between lung resistances and lung volume.

The authors hypothesized that relaxation of airway smooth muscle by halothane lessens the dependence of airway resistance on lung volume, and that halothane alters the relationship between pulmonary resistance and lung volume by changing both the airway and tissue components of pulmonary resistance. The relationship among airway resistance, tissue resistance, and lung volume was examined in mongrel dogs before and during the administration of halothane, both in airways with reduced smooth muscle tone (after vagotomy) and during moderate increases in smooth muscle tone caused by vagus nerve stimulation (VNS). Resistance were measured at several levels of positive end-expiratory pressure (PEEP, 4-15 cmH2O) using an alveolar capsule technique. Before halothane administration, airway resistance increased at low PEEP; VNS accentuated this increase. Tissue resistance increased at low PEEP only during VNS. Halothane had no significant effect on any resistance before VNS. During VNS, halothane markedly blunted increases in airway resistance and tissue resistance as PEEP decreased. The authors conclude that during stimulation of airway smooth muscle in dogs, halothane attenuates increases in airway resistance and tissue resistance with reductions in lung volume in dogs. Thus, moderate changes in lung volume have little effect on these resistances during halothane anesthesia under these conditions.     

A comparative study of the ileal conduit, Kock pouch and modified Indiana pouch

Between July 1986 and July 1988, 55 urinary diversion procedures were performed: 18 ileal conduits, 12 Kock pouches and 25 Indiana pouches. The different forms of urinary diversion were compared for patient selection, operative technical demands, postoperative complications, perioperative renal function, and short-term followup including re-hospitalizations, revisions, and pouch function. Patient selection was the same for the ileal conduit and Indiana pouch patients. Kock pouch patients were more highly selected for youth and health status. The operative technical demands of the ileal conduit and Indiana pouch were similar. The average operative time and blood loss for cystectomy and ileal conduit was 5:27 hours and 1290 cc's versus 5:30 hours and 1201 cc's for the Indiana pouch group. Postoperative complications and changes in renal function were similar among all three groups except for an increase in urinary anastomotic leaks in heavily irradiated ileal conduit patients. The ileal conduit patients required no re-hospitalizations or revisions; the Indiana pouch group had four re-hospitalizations and no revisions; the Kock pouch group had nine re-hospitalizations and three revisions. The day and night-time continence rate was 100% in both the Indiana and Kock pouch groups. The Indiana pouch has similar technical demands as the ileal conduit, has similar postoperative complications as the ileal conduit or Kock pouch, and functions well with a low revision rate. We conclude that the modified Indiana pouch can be just as safely and effectively accomplished in any patient requiring an ileal conduit.