THE T POUCH: AN ORTHOTOPIC ILEAL NEOBLADDER INCORPORATING A SEROSAL LINED ILEAL ANTIREFLUX TECHNIQUE

Purpose

At our institution the Kock ileal neobladder has been the primary form of urinary diversion after cystectomy. The few associated complications are primarily related to the intussuscepted antireflux afferent limb, including stones, stenosis and extussusception of the afferent nipple. We present a novel orthotopic ileal neobladder, the T pouch, with an innovative antireflux technique designed to prevent complications of the intussuscepted afferent nipple.

Material and Methods

From November 1996 through August 1997, 40 patients an average of 67 years old underwent construction of an orthotopic ileal neobladder (T pouch). Mean followup is 10.5 months (range 8 to 14). The T pouch incorporates an antireflux mechanism using a serosal lined ileal tunnel technique. Urinary reflux is prevented without ileal intussusception and with complete preservation of the blood supply to the afferent ileal segment. Followup in all cases includes clinical and functional results, and radiographic evaluation of the urinary reservoir and upper urinary tracts.

Results

One perioperative death (2.5%) and 5 early complications (12.5%) were unrelated to urinary diversion. There have been no late complications. All T pouch reservoirs had excellent capacity without evidence of urinary reflux. The upper urinary tracts remain unchanged or improved in all patients.

Conclusions

The T pouch is an orthotopic ileal neobladder that incorporates an effective, innovative antireflux mechanism created by a serosal lined ileal tunnel. Early clinical and functional results of this type of urinary diversion have been excellent. Furthermore, we suspect that this antireflux technique may eliminate the complications associated with an intussuscepted afferent nipple and maintain an effective antireflux mechanism.     

Potential Utility of Cardiorenal Biomarkers for Prediction and Prognostication of Worsening Renal Function in Acute Heart Failure

BackgroundMultiple different pathophysiologic processes can contribute to worsening renal function (WRF) in acute heart failure.Methods and ResultsWe retrospectively analyzed 787 patients with acute heart failure for the relationship between changes in serum creatinine and biomarkers including brain natriuretic peptide, high sensitivity cardiac troponin I, galectin 3, serum neutrophil gelatinase-associated lipocalin, and urine neutrophil gelatinase-associated lipocalin. WRF was defined as an increase of greater than or equal to 0.3 mg/dL or 50% in creatinine within first 5 days of hospitalization. WRF was observed in 25% of patients. Changes in biomarkers and creatinine were poorly correlated (r ≤ 0.21) and no biomarker predicted WRF better than creatinine. In the multivariable Cox analysis, brain natriuretic peptide and high sensitivity cardiac troponin I, but not WRF, were significantly associated with the 1-year composite of death or heart failure hospitalization. WRF with an increasing urine neutrophil gelatinase-associated lipocalin predicted an increased risk of heart failure hospitalization.ConclusionsBiomarkers were not able to predict WRF better than creatinine. The 1-year outcomes were associated with biomarkers of cardiac stress and injury but not with WRF, whereas a kidney injury biomarker may prognosticate WRF for heart failure hospitalization.     

Use of Single Lead VDD Pacing in Children

The development of transvenous ventricular pacing leads with proximal electrodes capable of atrial sensing and the recent availability of smaller generators has created the opportunity to treat children with complete AV block and normal sinus node function with a transvenous single lead VDD pacing system. Studies in adults have demonstrated this system to be efficacious with low complication rates. Transvenous single lead VDD pacemakers were implanted in ten children, aged 5–15 years, between December 1993 and April 1996, in our institution. The indications were complete AV block with severe bradycardia in 5 patients, second-degree or complete A V block following congenital heart surgery in 3, complete A V block with long QT syndrome in 1, and second-degree AV block and syncope in 1. There were no complications related to the procedure in any case. P and R wave amplitudes were measured and thresholds were determined intraoperatively on all patients. Amplitudes and thresholds were remeasured on seven patients with a mean follow-up of 17 months; Holter monitors were performed on seven patients with a mean follow-up of 16 months. P and H wave amplitudes were generally diminished at follow-up compared to initial values but remained within an acceptable range for all patients. Four patients required reprogramming after pacemaker insertion, 1 received an atrial lead for dual chamber pacing, 1 required repositioning for lead dislodgment. and 1 patient required a new lead for an inadequate ventricular pacing threshold. No patient had evidence of failure to sense or capture as evaluated by Halter monitoring at last follow-up. Single lead VDD pacing systems can be successfully used in properly selected children with high degree or complete AV block with normal sinus node function.     

The German Aortic Valve Registry (GARY): A Nationwide Registry for Patients Undergoing Invasive Therapy for Severe Aortic Valve Stenosis

Background The increasing prevalence of severe aortic valve defects correlates with the increase of life expectancy. For decades, surgical aortic valve replacement (AVR), under the use of extracorporeal circulation, has been the gold standard for treatment of severe aortic valve diseases. In Germany ~12,000 patients receive isolated aortic valve surgery per year. For some time, percutaneous balloon valvuloplasty has been used as a palliative therapeutic option for very few patients. Currently, alternatives for the established surgical procedures such as transcatheter aortic valve implantation (TAVI) have become available, but there are only limited data from randomized studies or low-volume registries concerning long-time outcome. In Germany, the implementation of this new technology into hospital care increased rapidly in the past few years. Therefore, the German Aortic Valve Registry (GARY) was founded in July 2010 including all available therapeutic options and providing data from a large quantity of patients.Methods The GARY is assembled as a complete survey for all invasive therapies in patients with relevant aortic valve diseases. It evaluates the new therapeutic options and compares them to surgical AVR. The model for data acquisition is based on three data sources: source I, the mandatory German database for external performance measurement; source II, a specific registry dataset; and source III, a follow-up data sheet (generated by phone interview). Various procedures will be compared concerning observed complications, mortality, and quality of life up to 5 years after the initial procedure. Furthermore, the registry will enable a compilation of evidence-based indication criteria and, in addition, also a comparison of all approved operative procedures, such as Ross or David procedures, and the use of different mechanical or biological aortic valve prostheses.Results Since the launch of data acquisition in July 2010, almost all institutions performing aortic valve procedures in Germany joined the registry. By now, 91 sites which perform TAVI in Germany participate and more than 15,000 datasets are already in the registry.Conclusion The implementation of new or innovative medical therapies needs supervision under the conditions of a well-structured scientific project. Up to now relevant data for implementation of TAVI and long-term results are missing. In contrast to randomized controlled trials, GARY is a prospective, controlled, 5-year observational multicenter registry, and a real world investigation with only one exclusion criterion, the absence of patients' written consent.     

A comparison of vincristine and doxorubicin infusional chemotherapy with methylprednisolone (VAMP) with the addition of weekly cyclophosphamide (C-VAMP) as induction treatment followed by autografting in previously untreated myeloma

In a sequential nonrandomized study, 204 consecutive unselected patients aged < 70 years received induction chemotherapy with infusional vincristine and adriamycin with oral methyl prednisolone (VAMP; n =75) or with additional cyclophosphamide, C-VAMP ( n =129). 38/129 C-VAMP patients also received verapamil during induction as part of a controlled trial with the aim to overcome drug resistance. A median of five courses (range 1–11) of chemotherapy were required before maximal response was attained and this was similar in both groups. An over-all response rate of 71% was noted at the end of induction. The complete remission (CR) rate with C-VAMP was 24%, which was significantly higher ( P =0.04) than the CR rate with VAMP alone (8%). The addition of verapamil did not alter the response rate of C-VAMP. Compliance to VAMP was overall 83% and not affected by the addition of cyclophosphamide. The proportion of patients going on to receive high-dose chemotherapy and an autograft was the same for VAMP and C-VAMP treated patients (71%). The median overall survival (OS) and progression-free survival (PFS) for the whole group were 4.4 years and 2.0 years and no difference in outcome was observed between the different treatment groups. Therefore the addition of weekly cyclophosphamide to VAMP induction therapy has significantly improved the response rates of previously untreated myeloma patients. C-VAMP was not more toxic and did not compromise the chances of receiving an autograft. Verapamil was without influence on any parameters in this study.     

A longitudinal study of New Zealand children's experience with alcohol

A longitudinal study assessed the use of alcohol and related measures among New Zealand children aged 9, 11, 13 and 15 years. The proportion of children who were abstainers was at a similar level to the adult population by age 15 years. Those remaining abstainers were more likely to have infrequently drinking parents and to have been warned of the bad effects of alcohol by their parents. In terms of amount consumed and frequency of drinking, there was an increase with age and a marked increase between the ages of 13 and 15 years. Frequency of drinking was positively associated with the frequency of drinking by the mother and father. Girls drank less than boys until the age of 15 years, when they drank slightly more and a difference in terms of socio-economic status (SES) emerged at age 15 years with tower SES groups drinking more.