Motility and intraluminal pressure of the ileocolonic junctional zone and adjacent bowel in a canine model

Summary The exact role of the ileocecal valve (ICV) at the junction of small and large bowel is not well understood. Bowel segments used for the construction of urinary reservoirs incorporate the ICV. In the Indiana pouch its natural continence is used as one principle for achieving continence of the efferent limb. Motor activity and pressure in the ICV, the ileum and colon were registered in eight dogs. Myogenic activity of the bowel consisted of slow weves, irregular spontaneous contractions and superimposed spikes. Pressures of 7.2±0.3 cmH₂O were recorded in the ileum and of 5.6±0.4 cmH₂O in the colon. The pressure in the ICV was 12.7±0.4 cmH₂O rising to 26.4±2.2 cmH₂O during spontaneous depolarization. Balloon dilatation of the ileum resulted in relaxation of the ICV in 76% of experiments, whereas colonic distension was followed by a pressure increase in the ICV region in 80% of experiments. In 16% of cases a relaxation of the ICV area and a weaker response after repeated dilatation was noted. These findings make the ICV an unreliable continence mechanism as its long-term continence can not be predicted despite intraoperative evaluation. Additional measures to ensure consistent continence at the ICV (e.g. electric stimulation) need to be studied.     

小儿阑尾输出道可控性肠膀胱术(附七例报告)

目的 探讨阑尾输出道可控性肠膀胱术在小儿泌尿外科的应用效果。方法 报道7例小儿阑尾输出道可控性肠膀胱术治疗经验。男3例女4例,平均年龄8岁。车祸致膀胱、石输尿管及双睾丸缺失1例,先天性完全性尿失禁4例（尿生殖窦畸形、膀胱外翻各1例,短尿道2例）,神经源性膀胱2例。结果 5例（70％）达到预期效果,2例仍有尿自尿道排出。结论 阑尾输出道可控性膀胱术对需行尿流改道的患儿是一种有效的手术方式。     

女性控尿机制的研究及其在原位新膀胱术中的应用

近10多年来,随着对女性人体盆腔和尿道局部解剖学的深入研究,临床泌尿外科医师对膀胱颈、尿道、横纹括约肌、尿道支持组织及这些结构的神经支配在女性控尿中的作用有了新的认识,指导和推动了原位新膀胱术在女性患者中的应用,提高了临床效果和患者生活质量。本文就有关女性控尿机制及其在原位新膀胱术中的应用进展作一介绍。     

An alternative continence tube for continent urinary reservoirs: evaluation of surgical technique,pressure and continence study in an ex-vivo model

Objective  Despite the large number of surgical techniques for continent cutaneous diversion described in literature, the creation of a reliable, continent and easily catheterizable continence mechanism remains a complex surgical procedure. Aim  Aim of this study was the evaluation of a new method for a catheterizable continence mechanism using stapled pig intestine. Methods  Small and large pig intestines were used for construction. A 3 or 6 cm double row stapling system was used. Three variations using small and large intestine segments were constructed. A 3 or 6 cm long stapler line was placed alongside a 12 Fr catheter positioned at the antimesenterial side creating a partially two-luminal segment. Construction time for the tube was measured. The created tube was then embedded into the pouch. Pressure evaluation of the continence mechanism was performed for each variation. Intermittent external manual compression was used to simulate sudden pressure exposure. Results  All variations were 100% continent under filling volumes of up to 700 ml and pressure levels of 58 ± 6 cm H₂O for large intestine and 266 ml and 87 ± 18 cm H₂O for small intestine, respectively. With further filling above the mentioned capacity suture insufficiency occurred but no tube insufficiency. Construction time for all variations was less than 12 min. Conclusion  The described technique is an easy and fast method to construct a continence mechanism using small or large intestine. Our ex vivo experiments have shown sufficient continence situation in an ex-vivo model. Further investigations in an in-vivo model are needed to confirm these results.     

肠膀胱扩大加阑尾输出道在小儿可控性尿流改道手术中的应用

目的 探讨肠膀胱扩大加阑尾输出道手术在小儿可控性尿流改道中的应用效果.方法小儿肠膀胱扩大加阑尾输出道可控性尿流改道手术患儿22例.男12例,女10例.年龄5～14岁,平均8岁.脊髓脊膜膨出术后致神经性膀胱11例,男童陈旧性骨盆骨折致后尿道断裂、反复手术后尿道狭窄伴尿失禁2例,女童陈旧性骨盆骨折致尿道狭窄合并尿道阴道瘘反复手术修补失败3例,尿生殖窦畸形伴高位肛门闭锁术后完全性尿失禁2例,膀胱外翻和尿道上裂膀胱颈重建术后尿失禁2例,男童后尿道瓣膜2例.肾、输尿管扩张积水17例28侧,其中15例24侧伴Ⅱ～Ⅴ级膀胱输尿管反流,术中行输尿管与贮尿囊再吻合术.患儿均自阑尾输出道间歇清洁导尿.术前与术后行尿动力学检查、IVU,B超、排尿性膀胱尿道造影及血尿素氮、肌酐和生化电解质等检查.比较手术前后膀胱及上尿路功能的变化,评估手术疗效. 结果 术后随访1.5～6.0年,平均3.6年.22例阑尾输出道均无漏尿.2例术后早期阑尾输出道皮肤造口狭窄,扩张1～3个月后插管顺利.2例仍自尿道漏尿,其中1例手术缝合膀胱颈口后治愈,1例进行盆底肌肉训练.术前和术后贮尿期末膀胱内压力分别为(45.47±14.15)、(16.24+5.25)cm H2O(1 cm H2O=0.098 kPa),膀胱最大测压容积分别为(65.5±43.5)、(337.0±189.50)ml,残余尿量(56.0±22.5)ml,导尿后完全排空,术前最大尿道闭合压力和术后最大输出道闭合压力分别为(35.24 ±14.46)、(78.40±20.15)cm H2O,膀胱顺应性分别为(8.25 ±7.33)、(26.75 ±8.45)ml/cm H2O,手术前后比较差异均有统计学意义(P<0.01).肾、输尿管积水较术前无加重,膀胱输尿管未见反流. 结论 肠膀胱扩大加阑尾输出道可控性尿流改道手术是治疗小儿膀胱和尿道解剖及功能障碍的一种有效方式,可以避免上尿路进一步损害,提高患儿生活质量.     

Atresia of the Ileocecal Junction with Agenesis of the Ileocecal Valve and Vermiform Appendix: Report of a Case

Intestinal atresia involving the ileocecal region is a very rare intestinal malformation, and the presence or absence of the ileocecal valve influences its surgical management. We report the case of a male newborn with a provisional diagnosis of distal ileal atresia, in whom laparotomy revealed that the entire ileocecal region was atretic with an absent ileocecal valve and appendix vermiformis. We resected the dilated terminal ileum together with the atretic segment and performed an ileocolic anastomosis between the terminal ileum and the transverse microcolon without valve reconstruction. When last seen, 8 months after the operation, the baby was developing normally. Ileocolic anastomosis without valve replacement appears to be sufficient if an ileocecal valve is completely absent and only a short segment of the terminal ileum is lost.     

阑尾倒置与脐吻合作输出道的可控性尿流改道术

目的　探讨带血管蒂游离阑尾倒置与脐吻合作输出道的可控肠膀胱术在泌尿外科的应用效果。　方法　 17例膀胱移行上皮细胞癌 ,均为多发、浸润肿瘤。男 14例 ,女 3例。年龄 43～ 6 6岁 ,平均 5 4岁。初发 6例 ,复发 11例。根治性全膀胱切除术后 ,采用带血管蒂游离阑尾倒置与脐吻合作输出道 ,行可控回肠、回结肠及乙状结肠膀胱术。　结果　全部患者手术顺利。 13例随访 6～ 38个月 ,效果满意 ,脐部造口隐蔽 ,14～ 16F导管插管排尿顺畅 ,无尿外溢 ,2例有轻度肾积水 ,血Cr、BUN均正常。　结论　带血管蒂游离阑尾倒置与脐吻合作输出道的可控肠膀胱术是一种较理想的手术方法     

Ureterosigmoidostomy in rats: A model for the study of bladder tumour carcinogenesis and cocarcinogenesis

Summary A modified Coffey I ureterosigmoidostomy has been developed in rats as a model of urinary diversion for studying bladder carcinogenesis and co-carcinogenesis. Diverted and sham-operated animals were killed at 1, 3 and 6 months. Excretory urograms revealed minimal hydroureteronephrosis in most diverted animals. Upper tract bacterial colonisation was 9 times more frequent in diverted animals. Approximately one-third of the diverted animals had focal cortical scarring; however, renal function was normal in all groups as assessed by serum creatinine and electrolytes. These studies indicate that ureterosigmoidostomy in rats is a satisfactory model of urinary diversion for studying carcinogenesis.     

肠代膀胱术中回肠反套入抗输尿管返流方法的临床研究

目的 评价肠代膀胱术中回肠反套入的抗输尿管返流作用。方法 患者5例，男4例，女1例。年龄48～67岁，平均61岁。均为浸润性移行细胞癌，行膀胱全切、回肠正位膀胱术。距回盲部屈氏韧带15cm处切取回肠30cm，近端回肠反套入4cm，回肠段远端肠管对系膜缘纵形剖开，U形缝合；套入肠管与对应肠片均切除1cm宽之黏膜，相应浆肌层可吸收线固定4针，对应黏膜缘缝合，防止套入肠管滑脱；双侧输尿管远端剖开6cm，侧侧吻合后经套入肠管引入，吻合口与套入肠管口间断缝合；U形肠管对折成储尿囊，与尿道吻合。术后定期行血生化、双肾B超、排泄性膀胱造影和尿动力学检查。结果 5例患者随访10～33个月。排尿次数白天3～5次，夜间0～3次；日间控尿100％，夜间控尿80％；尿动力学检查：最大尿流率9．5～31．5ml／s，膀胱容量350～710ml，平均433ml；剩余尿50～305ml；最大膀胱排尿压23～52cmH2O；膀胱出口无梗阻。B超检查双肾无积水。膀胱造影未见输尿管返流。结论 回肠正位膀胱术中回肠反套入方法有良好的抗输尿管返流作用。     

Fascicular anatomy and surgical access of the human pudendal nerve

The ability to access selectively distal nerve branches at the level of the compound pudendal nerve (PN) would allow control of multiple neural pathways and genitourinary functions at a single location. Nerve cuff electrodes can selectively stimulate individual fascicles; however the PN fascicular anatomy is unknown. The fascicular representation of distal branches was identified and traced proximally to create fascicle maps of 12 compound PNs in seven cadavers. Distal nerves were represented as groups of individual fascicles in the PN. Fascicle maps were consistent between specimens and along the PN within specimens. PN branch free length was 26±7.7 mm. PN cross-sections were relatively flat with major and minor diameters of 4.3±0.90 and 1.7±0.45 mm, respectively. Placing a nerve cuff on the PN is anatomically and surgically feasible. The PN fascicular anatomy, branch free length, and cross-section geometry are conducive to selective stimulation of distal nerves with a single nerve cuff electrode.     

Tumor induction and prophylaxis following different forms of intestinal urinary diversion in a rat model

Eighty Wistar rats were randomized into two groups. In group 1 vesicosigmoidostomy with proximal colostomy was performed, in group 2, vesicosigmoidostomy. The total tumor incidence did not differ significantly (group 1 10/40, 25%; group 2 13/40, 32.5%). The tumor spectrum differed, with more adenocarcinomas in group 2 (11/40, 27.5% vs 4/40, 10%;P=0.047) and urothelial carcinomas only in group 1 (5/40, 2.5%). One hundred and ten other Wistar rats were randomized into three groups. Animals in group A received vesicoileosigmoidostomy, group B, two-step vesicosigmoidostomy with initial separation of urine and the urocolonic anastomosis, group C, vesicosigmoidostomy. Significantly fewer adenocarcinomas were observed in group A (2/40, 5%) than in group B (16/40, 40%,P<0.002) and group C (9/30, 30%;P<0.007). These results indicate a similar cancer risk in all continent forms of urinary diversion, at least via colon. Ileal interposition seems to be an effective carcinoma prophylaxis following ureterosigmoidostomy. The proliferative instability at the urointestinal anastomosis is crucial for the pathogenesis and prophylaxis of this form of carcinogenesis, whereas urine seems to play only a minor role.     

心脏瓣膜置换手术死亡风险模型与体外膜肺氧合代替体外循环的适应证探讨

目的 建立心脏瓣膜病术前评估的死亡风险模型,并对手术病人进行评估,对体外膜肺氧合(ECMO)代体外循环的适应证进行初步探讨.方法 对4482例心脏瓣膜置换手术病人进行回顾性分析,选取性别,年龄,术前左心室射血分数(EF)、左心室舒张末径、肺动脉压、肾功能和是否合并冠心病7个临床指标作为住院死亡的可能影响因素.利用单因素分析进行筛选,用多因素Logistic回归确立死亡风险模型.根据模型,对此后的瓣膜病病人术前进行死亡风险评估,死亡概率≥10%的病例,随机分别给予常规手术或ECMO代替体外循环、术后转为心肺辅助.比较两种方法的手术病死率.采用SPSS11.5统计软件进行检验(α=0.05).结果 单因素分析除性别之外,其余6个因素均有统计学意义.Logistic回归建立死亡风险模型为Ln(P/1-P)=-4.3742+0.5192肾功能+0.1467年龄+0.3947EF+0.9390冠心病+0.5888肺动脉压+0.3287左室舒末径.此后常规手术52例,ECMO代体外循环术后转心肺辅助22例,两组性别、年龄、预计病死率构成比差异无统计学意义.两组预计病死率分别为(16.35±4.3)%和(16.21±5.19)%,差异无统计学意义(P<0.05).实际病死率分别为30.76%(16/52例)和9.09%(2/22例),差异有统计学意义(Pearson Chi-Square,P=0.047).结论 心脏瓣膜置换术前死亡风险评估,高龄、左心室低EF值、左室舒张末径过大或过小、肺动脉高压、肾功能不良、合并冠心病是危险因素,可以计算预计确切死亡概率.利用心脏瓣膜病死亡风险模型,对高风险(10%以上)病人进行ECMO代体外循环、术后转为心肺辅助,有利于降低手术病死率.     

部分胃体-窦部代膀胱术的临床应用及长期随访

目的探讨部分胃体-窦部代膀胱术的临床应用价值。方法回顾性分析30例胃代膀胱术患者的临床资料、实验室检查、影像学检查、膀胱镜及尿动力学检查结果。男17例，女13例。年龄21—69岁，平均55岁。原发病为膀胱癌24例，结核性膀胱挛缩6例。结果术后新膀胱贮尿功能良好，患者经尿道排尿，膀胱容量280—580ml，平均385ml；最大尿道压20—60cm H2O，平均49cm H2O；充盈期膀胱压5—15cm H2O，平均12cmH2O；最大膀胱压35—65cm H2O，平均55cmH2O；排尿期最大膀胱压28—60cm H2O，平均46cm H2O；最大尿流率10～28ml／s，平均18ml／s；剩余尿量5～85ml，平均20ml。随访9个月一24年，平均8．2年，无水、电解质代谢紊乱，无输尿管返流，无尿失禁及肾功能损害。4例出现会阴部、膀胱区疼痛；5例出现遗尿，术后3—6个月逐渐缓解；1例因膀胱结石再次手术。术后3．5年膀胱肿瘤复发1例，行经尿道膀胱肿瘤电切术。结论部分胃体一窦部代膀胱术后并发症少，相关生理指标接近正常。     

Transvaginal electrical stimulation in the treatment of genuine stress incontinence and detrusor instability

Electrical stimulation has been widely used in Europe to treat incontinence, but original studies and overall use of the device has been limited in North America. Forty-five patients with documented genuine stress incontinence, detrusor instability or mixed incontinence had self-administered therapy for 15 minutes twice daily, for a duration of 6 weeks. Treatment was delivered by a new stimulation device with an attached vaginal probe. Patients recorded treatment times, leak episodes and pad use. Objective measures included a pad test, standing stress test, standing CMG, and resting and dynamic urethral closure pressure profiles. The subjective success rates based on a questionnaire were 71% for genuine stress incontinence, 70% for detrusor instability, and 52% for combined incontinence. Objective testing for both types of incontinence did not show significant improvement after treatment. Four patients reported pain during use of the device, but most wished to continue the device in preference to other therapy.Supported in part by a grant from Hollister Incorporated.     

Resting and stress urethral pressures as a clinical guide to the mechanism of continence in the female patient

Urethral closure pressures are examined with respect to continence and aging. An attempt is made to interpret the inherent orientation sensitivity of microtip transducer profilometry. The transmission of cough pressures along the length of the urethra is also examined, showing that incontinence is associated with low transmission.     

Use and duration of antibiotic prophylaxis and the rate of urinary tract infection after radical cystectomy for bladder cancer: Results of a multicentric series

Objectives

To assess the rate of urinary tract infection (UTI), the characteristics of the bacterial aetiological agents involved, the type and duration of antibiotics used, and the clinical risk factors of UTI in a multi-institutional cohort of patients who had undergone radical cystectomy (RC).

改良Sigma直肠膀胱术中输尿管单腔、并腔肠吻合的疗效分析

目的 评价改良Sigma直肠膀胱术中输尿管单并腔肠吻合的疗效.方法 对14例膀胱多发移行细胞癌、1例膀胱腺癌根治性膀胱全切术后患者行改良Sigma直肠膀胱术.折叠25 cm直肠乙状结肠缝合成U形储尿囊,其中输尿管分别单腔与储尿囊吻合5例、双输尿管末端1.5～2.0cm并腔缝合后与储尿囊吻合10例.结果 15例患者控尿良好,无明显水电解质酸碱紊乱,术后15～22 d痊愈出院.13例随访8～24个月,其中输尿管单腔肠吻合4例出现吻合口狭窄、轻～重度肾积水,并腔肠吻合9例未出现肾积水.结论 改良Sigma直肠膀胱术创伤小、并发症少,患者可通过肛门括约肌自控排尿,无需配带尿袋或间断导尿,符合生理要求,提高了患者的生活质量;输尿管并腔后吻合口径大,不易发生狭窄等严重并发症.

Abstract：

Objective To make a comparison of curative effect of 1 and 2 ureters anastomosis in modified sigma operation. Methods Modified sigma operation was used after radical cystectomy in 14 cases of bladder transitional cell carcinoma and 1 case of adenocarcinoma of the bladder.We used a folded suture of 25 cm from the sigmoid colon to make the U-shaped urinary reservoirs to anastomose with the ureters in study group.Among study group,1 ureter was anastomosed with urinary reservoir in 5 cases.In the other 10 cases,1.5-2 cm of the terminal parts of 2 ureters were sutured tI am not sure what the authors mean by "big diamogether and then anastomosed with the urinary reservoir.Results 15 cases obtained good voiding control and no obvious water-electrolyte disturbance occurred.All the patients were cured and discharged within 15 to 22 days.Thirteen cases were followed-up in 8 to 24 month time period.Anastonmtic stenosis and moderate-severe hydronephrosis occurred in 4 cases with 1 ureter anastomosis.No hydronephrosis occurred in the 9 cases with 2 ureters anastomosis.Conclusions Modified sigma operation has the advantages of less injury and fewer complications.The patients can obtain self-control urination by anal sphincter without urine bags or intermittent catheterization,so the life quality of the patients is improved.Modified sigma operation with 2 ureters anastomosis has big diameter and there was a lower incidence of serious complications such as anastomotic stenosis.     

Cause of low compliance in a guinea-pig model of instability and low compliance

Experiments were performed to determine whether the low compliance seen in the bladders of guinea pigs with a partial bladder outflow obstruction was due to active or passive properties of the bladder wall. Sham-operated and obstructed animals were assessed urodynamically 6 to 12 weeks later. Three-quarters of the obstructed animals had developed low-compliance bladders. In vitro cystometry was performed on the isolated bladders in a physiological saline solution. The measurements were then repeated in Ca-free solution to abolish any contribution of smooth muscle contraction, and then in a high K, Ca-containing solution, which initiates maximum contraction in isolated detrusor strips. Bladder compliance was higher in the sham-operated animals than in obstructed animals. In sham-operated animals the compliance was decreased in the high K solution, but in the obstructed, low-compliance bladders the compliance did not change significantly under any experimental condition, suggesting that in this latter group the low compliance was caused by passive properties of the bladder wall. Changes in the viscosity of the bladder wall were assessed by monitoring the decline in pressure after a stepwise increase in bladder volume. No change in the viscosity of the obstructed bladder was detected. We conclude that the low compliance in the obstructed guinea pig is probably due to a change in the elasticity of the bladder wall.     

Evaluating the benefits of patterned stimulation in the treatment of osteoarthritis of the knee: a multi-center, randomized, single-blind, controlled study with an independent masked evaluator

OBJECTIVE: This study investigated the benefits of the combination of interferential (IF) and patterned muscle stimulation in the treatment of osteoarthritis (OA) of the knee. DESIGN: This was a multi-center, randomized, single-blind, controlled study with an independent observer. The study randomized 116 patients with OA of the knee to a test or control group. The test group received 15 min of IF stimulation followed by 20 min of patterned muscle stimulation. The control group received 35 min of low-current transcutaneous electrical nerve stimulation (TENS). Both groups were treated for 8 weeks. Subjects completed questionnaires at baseline and after 2, 4 and 8 weeks. Primary outcomes included the pain and physical function subscales of the Western Ontario MacMaster (WOMAC) OA Index and Visual Analog Scales (VAS) for pain and quality of life. RESULTS: Compared to the control group, the test group showed reduced pain and increased function. The test group showed a greater decrease in the WOMAC pain subscale (P=0.002), function subscale (P=0.003) and stiffness subscale (P=0.004). More than 70% of the test group, compared to less than 50% of the control group, had at least a 20% reduction in the WOMAC pain subscale. When analyzing only patients who completed the study, the test group had a nominally significant greater decrease in overall pain VAS. No significant between-group differences were observed in incidence of adverse events. CONCLUSIONS: In patients with OA of the knee, home-based patterned stimulation appears to be a promising therapy for relieving pain, decreasing stiffness, and increasing function.