Sigmoid neobladder in women after radical cystectomy

PURPOSE

Neobladder reconstruction using an intestinal segment is the common procedure of choice in men after cystectomy. Recently this procedure has been extended to women. We present our surgical and functional experience with the sigmoid neobladder in women.

MATERIALS AND METHODS

A total of 11 women 49 to 74 years old (mean age plus or minus standard deviation 60 +/- 8.5) with transitional cell carcinoma of the bladder underwent lower urinary tract reconstruction with a modified sigmoid neobladder after nerve and urethral support sparing cystectomy. After at least 3 months voiding pattern and continence status were evaluated. Pressure flow studies and uroflowmetry were performed, the urethral pressure profile and neocystourethral angle were measured, and blood chemistry was analyzed.

RESULTS

After at least 3 months complete daytime continence was achieved in 2 patients, while 8 had mild stress incontinence. At night 8 of the 11 women (72.7%) were continent with or without voiding at regular intervals. All except 1 patient voided to completion. Of the 2 patients with complete continence 1 needed clean intermittent catheterization 4 months postoperatively. Mean maximal urinary flow was 19.9 +/- 10.5 ml. per second. Excluding the woman who required catheterization mean residual urine volume was 15 +/- 13.7 ml. Postoperatively maximal urethral pressure was slightly lower and functional urethral length was about 10 mm. shorter than preoperatively. The mean neocystourethral angle was 131.9 +/- 21.7 degrees. Mean pH, bicarbonate and base excess were 7.38 +/- 0.03, 23. 48 +/- 2.34 mmol./l. and -0.92 +/- 2.50, respectively.

CONCLUSIONS

After nerve and urethral support sparing cystectomy a modified sigmoid neobladder may be constructed in women to obtain satisfactory continence and voiding results.

Changes in calcium metabolism and bone demineralization after orthotopic intestinal neobladder creation

PURPOSE

We evaluated calcium metabolism and bone demineralization by measuring specific markers for bone reabsorption and bone mineral density in patients with an intestinal neobladder.

MATERIALS AND METHODS

We studied 33 men 55 to 72 years old who underwent creation of an orthotopic sigmoid (23), ileocolic (8) or ascending colon (2) neobladder after cystectomy. Mean followup plus or minus standard deviation (SD) was 28.4+/-30.1 months (range 4 to 114). Serum electrolytes and arterial blood gases were measured. As markers of bone absorption we assayed urinary pyridinoline, deoxypyridinoline and N-terminal pyridinoline cross-linked telopeptides, and serum pyridinoline cross-linked C-terminal telopeptide of type I collagen. Bone mineral density of the spine and femur was determined by dual x-ray absorptiometry.

RESULTS

Mean blood pH plus or minus SD was 7.38+/-0.04 (range 7.29 to 7.43). Mean plasma bicarbonate was 22.9+/-3.4 mmol./l. and mean base excess was -1.63+/-3.61 mmol./l. Serum sodium, potassium, calcium, alkaline phosphatase and phosphate were normal in most patients. Mean serum chloride was 108.0+/-3.5 mEq./l., and was elevated in 9 of the 33 patients (27.3%). Serum intact parathyroid hormone was normal in all patients, osteocalcin was increased in 2 and 1alpha, 25-dihydroxyvitamin D3 was decreased in 2. Pyridinoline cross-linked C-terminal telopeptide of type I collagen was higher in 19 of 33 cases (57.6%) and N-terminal pyridinoline cross-linked telopeptides were elevated in 6 (18.2%). Pyridinoline and deoxypyridinoline were higher than normal in 19 (57.6%) and 7 (21.2%) patients, respectively. C-terminal telopeptide of type I collagen and deoxypyridinoline significantly correlated with serum pH (p = 0.017 and 0.0418, respectively). Z score for the bone mineral density of L2 to L4, the femoral neck and Ward's triangle was -0.350+/-1.031, -0.82+/-0.99 and -0.94+/-1.01, respectively.

CONCLUSIONS

In patients with a neobladder of intestinal segments metabolic acidosis results in increased bone absorption and decreased bone mass. Thus, attention should be given to bone metabolism in patients with even mild acidosis after orthotopic neobladder creation.

Nitric oxide production of rat Leydig and Sertoli cells is stimulated by round spermatid factor(s)

In this study, we provide evidence of cell-to-cell interaction between rat germ cells and Leydig or Sertoli cells in relation to nitric oxide (NO) production and inducible nitric oxide synthase (iNOS) messenger RNA (mRNA) expression. As a result of being cultured in a round spermatid-conditioned medium (RSd-CM), NO production in both Leydig and Sertoli cells increased in proportion to the length of the culture period. iNOS mRNA expression in both types of cells also increased in a dose-dependent manner as a result of being cultured with RSd-CM. This increase was detected as early as 3 h and was maintained up to 24 h. In contrast, neither NO production nor iNOS mRNA increased in either type of cell following culture in a pachytene spermatocyte-conditioned medium (PS-CM). Our findings suggest that RSd may control NO production of Leydig and Sertoli cells. This cell-to-cell interaction may be an important mechanism of regulation of testicular function.

Inhibition of apoptosis in cultured immature rat Leydig cells by human chorionic gonadotropin associated with Bcl-2 mRNA expression

Bcl-2 is the first identified negative regulator of apoptotic cell death. When the level of Bcl-2 mRNA in rat whole testes was examined in the present study, it gradually decreased in rats from 2.5 to 9 weeks old. We also examined the effect of human chorionic gonadotropin (hCG) on apoptosis and the level of Bcl-2 mRNA expression in immature Leydig cells in vitro. When the cells were cultured with serum free media (SFM), Bcl-2 mRNA levels gradually decreased. On the other hand, the level of Bcl-2 mRNA in cells treated with 50 ng/ml of hCG decreased at 6 h, but increased after 12 h. At 24 h, the level of Bcl-2 mRNA in the treated cells was almost the same as that of control cells (time = 0). At 12 h after the addition of various concentrations (from 0.1-1000 ng/ml) of hCG, Bcl-2 mRNA levels increased in a dose-dependent manner. An analysis of DNA fragmentation showed that treatment with hCG prevents the apoptosis of immature Leydig cells. Our findings suggest that Bcl-2 mRNA may be related to the programmed cell death of immature rat Leydig cells in vitro, which are inhibited by hCG.

Morphology of the intestinal tract in the white rhinoceros (Ceratotherium simum)

The intestinal tract of the white rhinoceros (Ceratotherium simun) was dissected. We observed a simple structure for the small intestine, duodenum, jejunum and ileum, and a well-developed large intestine, cecum, colon and rectus. The cecum consisted of a small chamber, whereas the colon was much enlarged; notably larger than that of the domesticated horse, which belongs to the same order, Perissodactyla. This suggests that in the white rhinoceros the cecum may be functionally replaced by the well-developed colon which may act as the main fermentation tank in this animal.

Diabetic nephropathy accompanied by iodine-induced non-autoimmune primary hypothyroidism: two case reports

We reported 2 diabetic patients with nephrotic syndrome due to advanced diabetic nephropathy complicated by non-autoimmune primary hypothyroidism. Hypothyroidism developed along with the anasarcous status. Histological examinations of the thyroid gland revealed almost normal thyroid follicles without lymphocytic infiltration. The amounts of thyroid hormone lost into the extravascular space such as in urine and ascites were not sufficient to cause hypothyroidism alone. Serum total iodine levels measured during the hypothyroidal state in both cases were definitely elevated, and the perchlorate discharge test of both cases showed positive discharge (24 and 34%, respectively). The thyroid functions normalized after iodine restriction in the first case and initiating hemodialysis in the second case, in parallel with normalization of serum total iodine levels. These findings suggest that impaired renal handling of iodine resulting in elevation of serum iodine levels, rather than an autoimmune mechanism or extravascular hormone loss, played a principal role in the development of primary hypothyroidism found in these 2 patients, probably through a prolonged Wolff-Chaikoff effect.

A U-shaped association between home systolic blood pressure and four-year mortality in community-dwelling older men

BACKGROUND

Several studies in older people have found a U-shaped or J-shaped association of blood pressure with mortality. The increased mortality associated with the lowest levels of blood pressure in older people have been explained by concurrent illnesses and frailty, but previous studies used blood pressure measured on a single occasion. Such a casual value is different from the long-term average of blood pressure. We investigated the relation between the average level of 5-day consecutive home blood pressure and mortality in older people while adjusting for potential confounding factors including morbidity and frailty at baseline.

METHODS

In 1992, 1186 community residents of a rural Japanese town, Kahoku, aged 65 or older, measured their blood pressure in their homes 20 times (four times per day, 5 consecutive days). The mean value of the 20 measurements was used to examine the association between home BP and subsequent 4-year mortality. A proportional hazards model was fitted while adjusting for activities of daily living impairment, medical history, antihypertensive medication, smoking, use of alcohol, and depression.

RESULTS

A total of 134 persons died during the four-year follow-up period. There was no significant evidence that frailty is more prevalent in the lowest or highest systolic BP group than in intermediate groups. A U-shaped association between the average level of home systolic blood pressure and mortality was found in men while adjusting for potential confounding factors, including morbidity and frailty. We also showed the U-shaped curve of the association of systolic BP with all cause and noncardiovascular mortality in the whole population and the linear association of systolic BP with cardiovascular mortality.

CONCLUSIONS

We showed a U-shaped association between the average level of systolic blood pressure measured at home and mortality in older men while adjusting for potential confounding factors including morbidity and frailty. Not only high home systolic BP, but also low home systolic BP, is an independent risk factor for mortality in older men. The mechanisms underlying the association between BP and mortality differ by levels of systolic BP. Cardiovascular deaths tended to be higher in the highest SBP group, and only noncardiovascular deaths were increased in the lowest SBP group. The latter finding suggests that low SBP may be not only an independent risk of mortality but also an indicator of a subclinical noncardiovascular comorbid condition.

Bryophyte 5S rDNA was inserted into 45S rDNA repeat units after the divergence from higher land plants

The 5S ribosomal RNA genes (5S rDNA) are located independently from the 45S rDNA repeats containing 18S, 5.8S and 26S ribosomal RNA genes in higher eukaryotes. Southern blot and fluorescence in situ hybridization analyses demonstrated that the 5S rDNAs are encoded in the 45S rDNA repeat unit of a liverwort, Marchantia polymorpha, in contrast to higher plants. Sequencing analyses revealed that a single-repeat unit of the M. polymorpha nuclear rDNA, which is 16,103 bp in length, contained a 5S rDNA downstream of 18S, 5.8S and 26S rDNA. To our knowledge, this is the first report on co-localization of the 5S and 45S rDNAs in the rDNA repeat of land plants. Furthermore, we detected a 5S rDNA in the rDNA repeat of a moss, Funaria hygrometrica, by a homology search in a database. These findings suggest that there has been structural re-organization of the rDNAs after divergence of the bryophytes from the other plant species in the course of evolution.

Effect of intracerebral and subdural hematomas on energy-dependent transport across the blood-brain barrier

Although both intracerebral and subdural hematomas induce brain edema, previous studies have indicated that they may have different cerebrovascular effects. Our own investigations have demonstrated that while subdural hematomas (SDH) are associated with ischemia this is not the case following intracerebral hematomas (ICH). Previous studies have demonstrated a decrease in energy-dependent transport of glutamine across the blood-brain barrier (BBB) following focal cerebral ischemia. The present study investigates this further by examining the effects of SDH, ICH, and intracerebral thrombin injections, an agent involved in ICH-induced injury, on blood to brain glutamine transport. The injection of 200 microL of blood into the subdural space induced a marked reduction in glutamine transport (Ki, influx rate constant) into the cerebral cortex at 4 and 24 h following SDH (sham, 105+/-4% of contralateral cortex; SDH 4 h, 63+/-5%, p<0.01; SDH 24 h, 47+/-12%, p<0.05). There were no significant changes in glutamine Ki in subcortical areas following SDH. Following ICH (200-microL clot); however, there were only modest decreases in glutamine Ki in subcortical areas (sham, 98+/-2% of right cortex; ICH 4 h, 91+/-5%, p<0.01; ICH 24 h, 91+/-2%, p<0.05). Intracerebral injection of thrombin (5U) had minimal effect on glutamine Ki, in subcortical areas, at 4 h and induced a modest decrease in transport at 24 h (sham, 98+/-2% of right cortex; thrombin 4 h, 98+/-2%; thrombin 24 h, 86+/-2%, p<0.05). The present studies demonstrate marked differences in the effects of ICH and SDH on BBB function.

Pharmacokinetics of natural human IFN-alpha in hemodialysis patients

A pharmacokinetic study of natural human interferon-alpha (IFN-alpha) was conducted in hemodialysis patients. Natural human IFN-alpha was intramuscularly (i.m.) administered to 8 hemodialysis patients at a single dose of 5 million IU and to 7 patients undergoing hemodialysis at the same dose once daily for 5 successive days. The serum antiviral activity was determined by a cytopathic effect bioassay. In the single dose study, the serum antiviral activity reached a maximum (Cmax) of 56.4 +/- 33.3 IU/ml at 8.3 +/- 2.7 h after dosing, and the area under the serum concentration-time curve (AUC0-24h) was 957.2 +/- 601.8 IU h/ml. The Cmax and AUC0-24h values at day 5 following the repeated dosing were both 2.6-fold higher than those of day 1, and the serum antiviral activity reached a steady state within 3 days after initiation of repeated administration. The serum antiviral activity in hemodialysis patients showed a tendency to increase compared with that in the subjects with normal renal function, but the magnitude of the differences was not great. In one nonhemodialysis patient with poor renal function (creatinine clearance < 30 ml/min), no increases in serum antiviral activity owing to repeated dosing were observed. The main adverse events seen were fever (4 of 13, 30.8%), leukopenia (3 of 13, 23.1%), and fatigue (2 of 13, 15.4%). These results suggest that dosage modifications of natural human IFN-alpha are unnecessary for patients with low renal function, even those undergoing hemodialysis.

Decrease in apoptosis of germ cells in the testes of infertile men with varicocele

To determine whether the regulation of apoptosis in the testes of patients with varicocele testes was abnormal, affecting germ-cell differentiation and sperm production, we studied apoptosis in the testes of normal men and infertile men with varicocele. In all, 56 testicular biopsy specimens were collected from 28 varicocele patients. The specimens from the testes of five normal volunteers with informed consent were used as controls. In situ end-labeled cells were counted with a CAS 200 image analyzer, and an apoptotic index (AI) was calculated by division of the number of labeled cells by the total number of spermatocytes and spermatogonia in over 20 seminiferous tubules. The apoptosis was also examined by electron microscope. The mean AI was 9.67 +/- 0.93% in normal testes (n = 5). In contrast, the mean AIs determined in the right and left testes of varicocele patients (n = 28) were 3.90 +/- 2.28% and 3.78 +/- 2.87%, respectively. The AIs recorded for the testes of varicocele patients were significantly lower than those noted for normal men (P < 0.05). In varicocele patients the AI obtained in the right testis was not statistically significantly different from that found in the left testis. The numbers of apoptotic cells per Sertoli cell also decreased in the testes of varicocele patients as compared with normal men (P < 0.01). Evaluation of all specimens, including the normal controls, revealed no significant correlation either between the AI and the sperm concentration on the seminogram or between the AI and Johnsen's mean score. There was also no relationship between the AI and the serum level of follicle-stimulating hormone, lutenizing hormone, testosterone, or estradiol. In conclusion, apoptosis is decreased in germ cells in the testes of infertile men with varicocele as compared with normal men.

Pressure pain threshold with and without iontophoretic anesthesia of the masseter muscle in asymptomatic males

AIMS

The pressure pain threshold (PPT) in the superficial masseter muscle was measured with and without cutaneous anesthesia to determine whether there would be a difference in PPT scores.

METHODS

In 14 healthy male subjects, cutaneous tissues in the target areas were anesthetized with lidocaine with the help of an iontophoretic device. As a control, physiologic saline solution was applied iontophoretically to the contralateral masseter site. The subject and the PPT examiner did not know which side contained anesthesia, and the selection of which side to anesthetize was done in a random fashion. Multiple PPT measurements were made in the target sites before and immediately after the iontophoretic anesthesia.

RESULTS

The PPT level on the lidocaine side was not statistically different from the PPT level recorded on the control side (339.0 +/- 87.6 kPa and 337.5 +/- 77.7 kPa, respectively).

CONCLUSION

Pressure pain sensation in the human masseter is not derived predominantly from the cutaneous tissues, but from the muscle itself.

The significance of the difference in bacterial adherence between bladder and ileum using rat ileal augmented bladder

OBJECTIVES

Intestinal segments are frequently used in the reconstruction of the urinary tract. Chronic bacteriuria is frequently observed in these patients, but the reason is not clearly understood. Therefore, we studied the difference in bacterial adherence between bladder and ileum using the rat ileal augmented bladder model to investigate the cause of chronic bacteriuria.

MATERIALS AND METHODS

Augmentation of the bladder using ileum and a sham operation were performed under sodium pentobarbital in 102 and 10 Sprague-Dawley rats, respectively. At three months after the operation, urinary pH and plasma concentration of sodium, chloride and potassium were measured and urinary culture was done. Urovirulence factors of Escherichia coli aspirated from augmented bladder were detected by polymerase chain reaction (PCR). Five to six rats with negative urinary cultures after the augmentation were used for each experimental cystitis. E. coli with type I pili aspirated from augmented rats and three clinically isolated strains of E. coli, C5 (type I pili, aerobactin), C92 (type I pili, aerobactin, P fimbriae), and C189 (type I pili, aerobactin, P fimbriae, CNF), were transurethrally inoculated into the augmented bladder of rats. Fourteen days after inoculation, rats were sacrificed and colony-forming units (CFU) per mg. of tissue of bladder and ileum were measured.

RESULTS

After operation, urinary pH and the serum level of chloride in all augmented groups were higher than those of the controls. Bacterial colonization was observed in 56 of 89 rats. Most of them were E. coli having only type I pili as a virulence factor. In contrast, the sham operated group revealed no bacterial colonization. In experimental cystitis, E. coli with only type I pili aspirated from augmented rats and E. coli C5 were clearly adhered to ileum rather than to bladder, but E. coli C92 and C189 showed no significant difference with respect to adherence to the two tissues. In experimental cystitis II, E. coli C5 with D-mannose were washed out in 3 of 5 rats by 14 days, while E. coli C5 without D-mannose were not washed out in all rats by 14 days.

CONCLUSIONS

These results suggested that the difference in bacterial adherence due to urovirulence factors, especially type I pili, is one of the main causes of asymptomatic bacteriuria after urinary reconstruction.

[An autopsy case of intracranial T cell type malignant lymphoma with fluctuating neuropsychological symptoms]

A 59-year-old man was admitted to the hospital due to leg edema. He had multiple sclerosis-like episodes of transient diplopia at the age of 36 years and spastic paraplegia at the age of 38. After admission he showed various fluctuating neuropsychological symptoms (disorientation, hallucination, apraxia, aphasia) and cranial nerve palsy. Magnetic resonance imaging revealed abnormal signal intensity in the right thalamus and deep white matter. The patient was diagnosed as having malignant lymphoma and treated with steroid therapy and chemotherapy. Although partial improvement of clinical findings was observed, recurrent cerebral hemorrhage followed. Autopsy findings revealed perivascular infiltration of T cells in the brain, spinal cord and other general organs.

[A case of true carcinosarcoma in bladder diverticulum]

We report a case of carcinosarcoma arising from a bladder diverticulum. A 71-year-old male was referred to our hospital for macroscopic hematuria. Two diverticula were identified in the left wall of the urinary bladder, one of which showed a broad-based tumor. The bladder tumor was resected using a transuretheral approach and the tumor was histologically diagnosed as leiomyosarcoma. The patient underwent partial resection of the bladder including the two diverticula and the tumor. Pathological examination revealed that the resected specimen was composed of three elements, transitional cell carcinoma (G3), squamous cell carcinoma, and leiomyosarcoma. Thus, the patient was diagnosed with carcinosarcoma. He died 5 months after surgery to remove the panperitonitis carcinomatosa. This case is the 38th reported case of bladder carcinosarcoma in Japan.

Klinefelter's syndrome in the male infertility clinic

The clinical features of patients with Klinefelter's syndrome attending a male infertility clinic have been investigated in order to consider their assisted reproduction treatment options. Over 12 years, a total of 148 patients with sterility due to azoospermia had Klinefelter's syndrome. Eight patients were shown by fluorescence in-situ hybridization (FISH) on metaphase spreads to be mosaic (46,XY/47,XXY), and 140 patients showed only 47,XXY. Small testes were observed in 95% of patients and gynaecomastia was seen in 12.4%. Half of the patients showed hypergonadotrophic hypogonadism, while others showed normogonadism (usually hypergonadotrophic). Spermatozoa were observed in semen from one patient with mosaicism and one without. Three-colour FISH revealed hyperploidy in 2.7% and 2.3% of these spermatozoa respectively. Multiple-site testicular biopsies in five recent patients were performed and yielded a specimen with round and elongated spermatids in one patient with 47,XXY karyotype. This sample was cryopreserved for future intracytoplasmic sperm injection. At follow-up, 46% of couples had chosen artificial insemination with donor sperm, and none had chosen adoption. Two patients developed testicular tumours, one a mature teratoma and the other a Leydig cell tumour. Two patients required androgen replacement therapy.

Assisted reproduction technology for patients with congenital bilateral absence of vas deferens

PURPOSE

We investigate the frequency of cystic fibrosis transmembrane conductance regulator gene mutations in Japanese patients with congenital bilateral absence of the vas deferens, and assess treatment outcomes of assisted reproduction interventions.

MATERIALS AND METHODS

In 10 Japanese patients with bilateral congenital absence of the vas deferens genetic analysis was performed for known frequent mutations of the cystic fibrosis transmembrane conductance regulator gene using polymerase chain reaction amplification followed by dot-blot hybridization with the allele-specific oligonucleotide probes and direct sequencing. Intracytoplasmic sperm injection using spermatozoa retrieved from the testes was performed in 7 of the couples.

RESULTS

No known mutations of the gene were detected in the patients. However, analysis of the polythymidine tract polymorphism in intron 8 revealed 30% allele frequency of 5T. Pregnancy was achieved in 7 cycles of intracytoplasmic sperm injection using spermatozoa retrieved from the testes.

CONCLUSION

The 5T variant in intron 8 polythymidine tract was identified with high allelic frequency in Japanese patients with congenital bilateral absence of the vas deferens, suggesting that the disease in Japan is also partially caused by this particular mutation of the cystic fibrosis transmembrane conductance regulator gene. Modern assisted reproduction technology offers an important option for patients with congenital bilateral absence of the vas deferens.

Cloning and studies of the mouse cDNA encoding Smad3

Following stimulation by the transforming growth factor-beta (TGF-beta) family in the cytoplasm, the Smad family is phosphorylated and translocated to the nucleus and activates several gene transcriptions. In this study, the mouse Smad3 cDNA including the open reading frame (ORF) was cloned from the mouse brain using a RACE (rapid amplification of cDNA ends) technique, and its expression pattern was analyzed in mouse tissue using northern blot. The predicted amino acid (aa) sequences of mouse Smad3 showed a high homology with human Smad3 (99.3%) and mouse Smad2 (85.4%). It revealed that this protein may be highly conserved in different species of mammals. Northern blot analyses revealed that Smad3 was highly expressed in the brain and ovary, and that the size of major transcript was about 5.7 kb. In situ hybridization analyses revealed the high expression of Smad3 was detected in the pyramidal cells of the hippocampus, the granule cells of the dentate gyrus, the granular cells of the cerebral cortex and the granulosa cells of the ovary. Smad3 may be essential transducer of signals from TGF-beta and activin in these cells.

Clinical outcome of microsurgery for obstructive azoospermia

BACKGROUND

Recent technical advances in microscopy have greatly improved the reconstruction of the seminal tract in cases of obstructive azoospermia.

METHODS

We evaluated the clinical outcome of 28 patients with obstructive azoospermia who underwent microsurgical reconstruction (i.e. vasovasostomy or unilateral epididymovasostomy). Diagnoses included postvasectomy (n = 9), childhood inguinal herniorrhaphy (n = 10) and cases of unknown cause (n = 9). Six of the unknown cases proved to be inoperable. We analyzed the outcome of the surgical reconstructions of operable cases according to the causes of obstruction, duration of obstruction, quality of the fluid obtained from the distal seminal tract (concentration, morphology and motility of sperm) and the histologic findings of the testis.

RESULTS

The surgical outcome was analyzed with regard to the incidence of patency and pregnancy. The incidence of patency achieved in nine vasectomy cases was 89%, while the incidence of pregnancy was 44%. In contrast, the incidence of patency in the nine operable cases with herniorrhaphy was 44%, while the pregnancy rate was 0%. Of four cases of unknown cause who underwent epididymovasostomy, the incidence of patency was 100% and the incidence of pregnancy was 75%. The outcomes were worse in post-vasectomy cases with long-term obstruction of more than 10 years; however, this was not statistically significant. The outcome was significantly worse in cases with low sperm concentrations. There was no significant relationship between histologic findings and surgical outcome.

CONCLUSIONS

The surgical outcome of vasovasostomy of postherniorrhaphy cases was significantly worse than that of post-vasectomy cases. With regard to epididymovasostomy, a unilateral repair was clinically evaluated.

Troglitazone combination therapy in obese type 2 diabetic patients poorly controlled with alpha-glucosidase inhibitors

The efficacy and safety of treatment with troglitazone combined with an alpha-glucosidase inhibitor, in obese type 2 diabetic patients who were previously administered alpha-glucosidase inhibitors alone, in improving glycaemic control and reducing insulin resistance were studied. Obese type 2 diabetic patients, poorly controlled with alpha-glucosidase inhibitors, were randomized to receive either oral troglitazone 200 mg twice daily (22 patients: group A) or a placebo (20 patients: group B) in addition to their usual alpha-glucosidase inhibitor. In group A, significant decreases in the mean levels of haemoglobin A1c and basal plasma insulin levels were observed 6 months after the start of combined therapy. Serum triglyceride levels significantly decreased but serum lactic acid dehydrogenase and body weight significantly increased. New systemic oedema was observed in six patients. Combined therapy with troglitazone and alpha-glucosidase inhibitors may be effective for diabetic metabolic abnormalities, although the potential development of adverse effects such as body-weight gain and systemic oedema demands vigilance.

Long-term experience with orthotopic reconstruction of the lower urinary tract in women

PURPOSE

We investigated the long-term outcome of orthotopic neobladders in women.

MATERIALS AND METHODS

At our institutions 8 women have undergone lower urinary tract reconstruction with an orthotopic neobladder and have been followed for more than 4 years. After urethral sparing cystectomy the neobladder was constructed and connected to the native urethra. Late complications were analyzed, and voiding function was evaluated by a pressure flow micturition study and bead-chain cystourethrography.

RESULTS

No late complications related to the surgery were noted. Of the 8 patients 7 were completely dry day and night. Four patients with ileal neobladder required clean intermittent catheterization, and hypercontinence might have been caused by downward migration of the neobladder and reduced neobladder pressure at voiding. No recurrence in the native urethra was noted, and all patients were satisfied postoperatively.

CONCLUSIONS

These results of orthotopic neobladder in women are encouraging. Overall patient satisfaction was excellent. An international collaborative study is necessary to achieve the number of patients required to determine the ideal orthotopic neobladder for women.